Fetal Alcohol Spectrum Disorder (FASD) Center for Excellence

Voluntary Customer Satisfaction Surveys to Implement Executive Order 12862 in the Substance Abuse and Mental Health Services Administration (SAMHSA)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0197 can be found here:

Documents and Forms

Document Name Document Type
Form Forms Fetal Alcohol Spectrum Disorder (FASD) Center for Excellence Form and Instruction
Forms Attachments A-J ATTACHMENT A-J.doc Form and Instruction
FASD- Training &TA - Supporting Statement.doc Supporting Statement IC Document
OMBTransLet5-2009.wpd Justification Letter IC Document

Information Collection (IC) Details

IC Title:	Fetal Alcohol Spectrum Disorder (FASD) Center for Excellence	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	Forms	Attachments A-J	ATTACHMENT A-J.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,405	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 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	6,685	0	0	0	0	0
Annual IC Time Burden (Hours)	601	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	FASD- Training &TA - Supporting Statement.doc	02/18/2009
Justification Letter	OMBTransLet5-2009.wpd	02/18/2009

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