Information Collection

Clinic Leadership Interview Guide

IC 252006 under ICR 202202-0920-001 · OMB 0920-1379.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920 Clinic Leadership Interview Guide	Form and Instruction
0920 Clinic Leadership Interview Guide Att 3g Clinic Leader Intvw.docx	Form and Instruction
Att 8d Training Module 1.pdf Training Module 1	IC Document
Att 8e Training Module 2.pdf Training Module 2	IC Document
Att 8f Training Module 3.pdf Training Module 3	IC Document

IC Title:

Agency IC Tracking Number:

0920-21HI

Is this a Common Form? No

IC Status: New

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	0920	Clinic Leadership Interview Guide	Att 3g Clinic Leader Intvw.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2	2
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.