OWH Prevention Award - SBIRT Provider Knowledge and Confidence Survey

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.