Attachment B – SHARE Approach evaluation clinician and staff surveys

Evaluation of the SHARE Approach Model

Documents and Forms

Document Name Document Type
Form 1 Attachment B – SHARE Approach evaluation clinician and staff surveys Form and Instruction
1 Card survey (patient) Patient Card Survey_Clean_3.18.2020.docx Form and Instruction
1 Card survey (patient) Patient Card Survey_Clean_3.18.2020.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment B – SHARE Approach evaluation clinician and staff 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	1	Card survey (patient)	Patient Card 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: 6,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	200	200
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.