Community Program Clinical Staff - Baseline

State Targeted Response to the Opioid Crisis (Opioid STR) Evaluation

Documents and Forms

Document Name Document Type
Form Community-Program Community Program Clinical Staff - Baseline Form and Instruction
Community-Program Community-Program Clinical Staff Baseline Attachment 7. Opioid STR Community-Program Clinical Staff Baseline Interview Protocol 7.5.17.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Community Program Clinical Staff - Baseline	Agency IC Tracking Number:

Is this a Common Form? No		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	Community-Program Clinical Staff Baseline	Community-Program Clinical Staff Baseline	Attachment 7. Opioid STR Community-Program Clinical Staff Baseline Interview Protocol 7.5.17.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	120	120
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.