Information Collection

OWH Prevention Award - SBIRT Provider Knowledge and Confidence Survey

IC 235505 under ICR 201708-0990-001 · OMB 0990-0379.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0379 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Provider SBIRT Knowledge and Confidence Survey_Individual (Providers)_final.docx	Other-Survey
OMB_Clearance_Submission_Form_OWHPA - Erie County DOH - SBIRT Provider Knowledge and Confidence Survey - SSA mini.doc OWHPA SBIRT Provider Knowledge and Confidence Survey - SSA mini	IC Document

IC Title:

OWH Prevention Award - SBIRT Provider Knowledge and Confidence Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey			Provider SBIRT Knowledge and Confidence Survey_Individual (Providers)_final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OWHPA SBIRT Provider Knowledge and Confidence Survey - SSA mini	OMB_Clearance_Submission_Form_OWHPA - Erie County DOH - SBIRT Provider Knowledge and Confidence Survey - SSA mini.doc	03/28/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.