Information Collection

Clinical staff questionnaire

IC 238231 under ICR 201910-0920-007 · OMB 0920-1285.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Clinical staff questionnaire	Form
Clinical Staff Questoinnaire Attachment E3 Clinical Staff Questionnaire.docx	Form
Attachment I3 Clinical Staff Questionnaire Screenshot.pdf Clinical Staff questionnaire - screenshots	IC Document

IC Title:

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	none	Clinical Staff Questoinnaire	Attachment E3 Clinical Staff Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiolgic Studies and Suveillance of Disease Problems

FR Citation: 51 FR 226

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	265	265

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Clinical Staff questionnaire - screenshots	Attachment I3 Clinical Staff Questionnaire Screenshot.pdf	10/22/2019

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