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[NCIPC] Three-Month Survey: Module WB4518, Talking about Naloxone 0920-1050-24DW
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction n/a Talking about Naloxone survey Att. 3_Three-Month Survey Instrument_Module WB4518, Talking about Naloxone.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

 

100 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   100 %

  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 100 0 100 0 0 0
Annual IC Time Burden (Hours) 25 0 25 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Privacy Assessment Att. 1_OMB Privacy Determination_Three-Month Survey_Module WB4518, Talking about Naloxone-Collection of Routine Customer Feedback (002).pdf 03/21/2024
Survey Screenshots Att. 4_Screenshots_ Three-Month Survey_Module WB4518, Talking about Naloxone_.docx 03/21/2024
GenIC Request Template Att. 2_1050_GenIC_Request Template Service Delivery_ Three Month Survey_Module WB4518 Talking about Naloxone.docx 03/21/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.