Clinical Screening Tool Survey

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

Documents and Forms

Document Name Document Type
Form 2900-0876 Clinical Clinical Screening Tool Survey Form and Instruction
Form 2900-0876 Clinical Clinical Screening Tool Survey Form and Instruction
2900-0876 Clinical 2900-0876 Clinical Screening Tool Survey Clinical Screening Tool Wireframe.pdf Form and Instruction
2900-0876 Clinical 2900-0876 Clinical Screening Tool Survey Clinical Screening Tool Wireframe.pdf Form and Instruction
ICR Template_A11 Section 280 Clearance.pdf Clinical Screening Tool Survey IC Document
ICR Template_A11 Section 280 Clearance.pdf Clinical Screening Tool Survey IC Document

Information Collection (IC) Details

IC Title:	Clinical Screening Tool Survey	Agency IC Tracking Number:	2900-0876 Clinical Screening Tool Survey

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	2900-0876 Clinical Screening Tool Survey	2900-0876 Clinical Screening Tool Survey	Clinical Screening Tool Wireframe.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Clinical Screening Tool Survey	ICR Template_A11 Section 280 Clearance.pdf	10/19/2023

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