Information Collection

Self-administered implementation surveys with clinical staff at 30 months

IC 237428 under ICR 201908-0935-001 · OMB 0935-0246.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0246 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form N Self-administered implementation surveys with clinical staff at 30 months Self-administered implementation surveys with clinical staff at 30 months	Form and Instruction
Form Q Consent form - Self-administered implementation surveys with clinical staff at 30 months Self-administered implementation surveys with clinical staff at 30 months	Form
N Self-administered implementation surveys with clinical s Attachment N - Clinical staff self-administered implementation survey at 30 months.docx	Form and Instruction
Q Consent form - Self-administered implementation surveys Attachment Q Consent form for clinical staff self-administered implementation survey at 30 months.docx	Form

IC Title:

Self-administered implementation surveys with clinical staff at 30 months

Agency IC Tracking Number:

Is this a Common Form? No

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
Form and Instruction	N				Yes	Yes	Fillable Fileable
Form	Q				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 774

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	774	774
Annual IC Time Burden (Hours)	387	387
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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