Clinical staff self-administered baseline surveys

Safety Program in Perinatal Care (SPPC)-II Demonstration Project

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.