Information Collection

Self-administered implementation surveys with clinical staff at 18 months

IC 237426 under ICR 202105-0935-001 · OMB 0935-0246.

Documents and Forms

Document Name Document Type
Form M Self-administered implementation surveys with clinical staff at 18 months Form and Instruction
M Self-administered implementation surveys with clinical s Attachment M - Clinical staff self-administered implementation survey at 18 months.docx Form and Instruction
M Self-administered implementation surveys with clinical s Attachment M - Clinical staff self-administered implementation survey at 18 months.docx Form and Instruction
P Consent form - Self-administered implementation surveys Attachment P Consent form for clinical staff self-administered implementation survey at 18 months.docx Form
P Consent form - Self-administered implementation surveys Attachment P Consent form for clinical staff self-administered implementation survey at 18 months.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Self-administered implementation surveys with clinical staff at 18 months	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	M	Self-administered implementation surveys with clinical staff at 18 months	Attachment M - Clinical staff self-administered implementation survey at 18 months.docx		Yes	Yes	Fillable Fileable
Form	P	Consent form - Self-administered implementation surveys with clinical staff at 18 months	Attachment P Consent form for clinical staff self-administered implementation survey at 18 months.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)	387	387
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.