Information Collection

Clinical staff self-administered baseline surveys

IC 237416 under ICR 202009-0935-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 G Clinical staff self-administered baseline surveys	Form and Instruction
G e) Clinical staff self-administered baseline surveys Attachment G - Clinical staff self-administered baseline survey.docx	Form and Instruction
H Consent form Attachment H Clinical staff self-administered baseline consent form.docx	Form and Instruction

IC Title:

Clinical staff self-administered baseline surveys

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	G	e) Clinical staff self-administered baseline surveys	Attachment G - Clinical staff self-administered baseline survey.docx		Yes	Yes	Fillable Fileable
Form and Instruction	H	Consent form	Attachment H Clinical staff self-administered baseline consent form.docx		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	Previously Approved
Annual Number of Responses for this IC	774	774
Annual IC Time Burden (Hours)	325	325
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.