Acceptability Survey of ARI Campaign for University of Utah Pediatric Clinic Champions

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⚠️ Notice: This information collection may be referencing outdated material.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 0920-1071 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1071 Acceptability Survey of ARI Campaign for University of Utah Pediatric Clinic Champions Form and Instruction
0920-1071 Provider Acceptibility Survey Acceptaiblity Survey_Peds_Providers_w Footer final.docx Form and Instruction
0920-1071 Champions Acceptability Survey Peds Acceptability Survery for Clinic Champions_wFooter final.docx Form and Instruction
Service_Delivery_Fast_Track_ Acceptability_Survey_ARI_Campaign_Combined_5-28-19.pdf Service Delivery Fasttrack Template IC Document
4. E-mail Invitation Script for Clinic Champions ICRO.docx Email Invite IC Document
8. Consent Cover Letter for Clinic Champions and Providers.doc Consent Letter IC Document
020717KF-NE-signed.pdf HS Determination IC Document

Information Collection (IC) Details

IC Title:	Acceptability Survey of ARI Campaign for University of Utah Pediatric Clinic Champions	Agency IC Tracking Number:	0920-1071-19AJE

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
Form and Instruction	0920-1071	Provider Acceptibility Survey	Acceptaiblity Survey_Peds_Providers_w Footer final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1071	Champions Acceptability Survey	Peds Acceptability Survery for Clinic Champions_wFooter final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 206	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	206	206
Annual IC Time Burden (Hours)	103	103
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Service Delivery Fasttrack Template	Service_Delivery_Fast_Track_ Acceptability_Survey_ARI_Campaign_Combined_5-28-19.pdf	06/04/2019
Email Invite	4. E-mail Invitation Script for Clinic Champions ICRO.docx	06/04/2019
Consent Letter	8. Consent Cover Letter for Clinic Champions and Providers.doc	06/04/2019
HS Determination	020717KF-NE-signed.pdf	06/04/2019

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