NLM Distance Learning Mentoring Program Study

Request for Generic Clearance to Conduct Voluntary Customer/Partner Surveys(NLM)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0476 can be found here:

Documents and Forms

Document Name Document Type
Form 1 NLM Distance Learning Mentoring Program Study Form and Instruction
1 Instruction rating Instrument Attachment 1_ NLM LHC - Instruction Rating Instrument.doc Form and Instruction
2 Essay Completion Instrument Attachment 2_ NLM LHC - Essay Completion Instrument.docx Form and Instruction
3 General Inventory Instrument Attachment 3_ NLM LHC - General Inventory Instrument (Kuder Screen Shots).pdf Form and Instruction
4 Health Inventory Instrument Attachment 4_ NLM LHC - Health Inventory Instrument.docx Form and Instruction
NLM GC form_ Distance Learning Mentoring_Nov 2014.doc NLM Distance Learning GC Form IC Document
NLM LHC SSA _Generic Sub-study Nov 2014.docx Mini SSA NLM Distance Learning Mentoring Program Study IC Document
NLM LHC SSB_Generic Sub-study Nov 2014.doc Mini SSB NLM Distance Learning Mentoring Program Study IC Document

Information Collection (IC) Details

IC Title:	NLM Distance Learning Mentoring Program Study	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Instruction rating Instrument	Attachment 1_ NLM LHC - Instruction Rating Instrument.doc	No		Paper Only
Form and Instruction	2	Essay Completion Instrument	Attachment 2_ NLM LHC - Essay Completion Instrument.docx	No		Paper Only
Form and Instruction	3	General Inventory Instrument	Attachment 3_ NLM LHC - General Inventory Instrument (Kuder Screen Shots).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	4	Health Inventory Instrument	Attachment 4_ NLM LHC - Health Inventory Instrument.docx	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	188	188
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
NLM Distance Learning GC Form	NLM GC form_ Distance Learning Mentoring_Nov 2014.doc	11/06/2014
Mini SSA NLM Distance Learning Mentoring Program Study	NLM LHC SSA _Generic Sub-study Nov 2014.docx	11/06/2014
Mini SSB NLM Distance Learning Mentoring Program Study	NLM LHC SSB_Generic Sub-study Nov 2014.doc	11/06/2014

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