Practicum Participant Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (OD/OER)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Practicum Participant Survey Form and Instruction
1 Practicum Participant Survey Practicum Survey Screen Shots_03202012.docx Form and Instruction
Practicum Survey Invitation Screen Shot_03202012.docx Practicum Survey Invitation Screen Shot_03202012 IC Document
Fast Track Template ODS Survey Request for Approval _ March_ 20_ 2012.doc Fast Track Template ODS Survey Request for Approval _ March_ 20_ 2012 IC Document
Word Version ODS_Practicum Eval_Final Survey_03202012.docx Word Version ODS_Practicum Eval_Final Survey_03202012 IC Document

Information Collection (IC) Details

IC Title:	Practicum Participant Survey	Agency IC Tracking Number:

IC Status: New

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	Practicum Participant Survey	Practicum Survey Screen Shots_03202012.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 381	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	381	0	0	0	0	0
Annual IC Time Burden (Hours)	159	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Practicum Survey Invitation Screen Shot_03202012	Practicum Survey Invitation Screen Shot_03202012.docx	05/01/2012
Fast Track Template ODS Survey Request for Approval _ March_ 20_ 2012	Fast Track Template ODS Survey Request for Approval _ March_ 20_ 2012.doc	05/01/2012
Word Version ODS_Practicum Eval_Final Survey_03202012	Word Version ODS_Practicum Eval_Final Survey_03202012.docx	05/01/2012

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