Attachment E: Learning Collaborative Self-Assessment

Identifying and Testing Strategies for Management of Opioid Use and Misuse in Older Adults in Primary Care Practices

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0258 can be found here:

Documents and Forms

Document Name Document Type
Form 5 Attachment E: Learning Collaborative Self-Assessment Form and Instruction
5 Attachment E: Learning Collaborative Self-Assessment Attachment E. Self-Assessment Questionnaire.docx Form and Instruction
5 Attachment E: Learning Collaborative Self-Assessment Attachment E. Self-Assessment Questionnaire.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment E: Learning Collaborative Self-Assessment	Agency IC Tracking Number:

Is this a Common Form? No		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	5	Attachment E: Learning Collaborative Self-Assessment	Attachment E. Self-Assessment Questionnaire.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24	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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.