Client Check-in Questionnaire

Evaluation of Medication- Assisted Treatment (MAT) for Opioid Use Disorders Study

OMB: 0920-1218

IC ID: 228976

Information Collection (IC) Details

View Information Collection (IC)

Client Check-in Questionnaire
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form none Check-in Questionnaire - English Attachment 5 Client Check-In.docx Yes Yes Fillable Fileable
Form none Client Check-in Questionnaire - Spanish Attachment 5 Client Check-In Form_spanish 17ACE_MAT.docx Yes Yes Fillable Fileable

Health Health Care Services

Epidemiologic Studies and Surveillance of Disease Problems  57 FR 62812

1,187 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,374 0 0 0 0 2,374
Annual IC Time Burden (Hours) 594 0 0 0 0 594
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

© 2024 OMB.report | Privacy Policy