Information Collection

Clinician survey

IC 241465 under ICR 202004-0935-004 · OMB 0935-0253.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0253 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Clinician survey	Form and Instruction
3 Post-training survey to assess experiences with SHARE tr Clinician Post-survey_Clean_3.18.2020.docx	Form and Instruction
3 Pre-training clinician survey to assess prior experience Clinician Pre-survey_Clean_3.18.2020.docx	Form and Instruction
3 Clinician survey to assess use of SHARE two months follo Clinician Pre-survey_Clean_3.18.2020.docx	Form and Instruction

IC Title:

Clinician survey

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	Available Electronically?	Electronic Capability
Form and Instruction	3	Post-training survey to assess experiences with SHARE training:	Clinician Post-survey_Clean_3.18.2020.docx	No	Fillable Fileable
Form and Instruction	3	Clinician survey to assess use of SHARE two months following training	Clinician Pre-survey_Clean_3.18.2020.docx	No	Fillable Fileable
Form and Instruction	3	Pre-training clinician survey to assess prior experience with SDM	Clinician Pre-survey_Clean_3.18.2020.docx	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	33	33
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.