Shared Decision-Making in Mental Health Decision Support Tools

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⚠️ Notice: This information collection may be referencing outdated material.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 Survey #1 Consumer Shared Decision-Making in Mental Health Decision Support Tools Form and Instruction
Survey #1 Consumer Survey #1 Consumer View of Workbook Survey #1 Consumer View of Workbook.pdf Form and Instruction
Survey #2 Provider Survey #2 Provider View of Workbook Survey #2 Provider View of Workbook.pdf Form and Instruction
Survey #3 Consumer Survey #3 Consumer View of Decision Aid Survey #3 Consumer View of Decision Aid.pdf Form and Instruction
Survey #4 Provider Survey #4 Provider View of Decision Aid Survey #4 Provider View of Decision Aid.pdf Form and Instruction
OMBTransLet12-2010.wpd Memo IC Document
OMB Justification.doc Justification IC Document
Product #1 What is Right for Me Workbook.pdf Product #1 What is Right for Me Workbook IC Document
Product #2 Supporting Choice Workbook.pdf Product #2 Supporting Choice Workbook IC Document

Information Collection (IC) Details

IC Title:	Shared Decision-Making in Mental Health Decision Support Tools	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	Survey #1 Consumer View of Workbook	Survey #1 Consumer View of Workbook	Survey #1 Consumer View of Workbook.pdf	Yes	Yes	Paper Only
Form and Instruction	Survey #2 Provider View of Workbook	Survey #2 Provider View of Workbook	Survey #2 Provider View of Workbook.pdf	Yes	Yes	Paper Only
Form and Instruction	Survey #3 Consumer View of Decision Aid	Survey #3 Consumer View of Decision Aid	Survey #3 Consumer View of Decision Aid.pdf	Yes	Yes	Paper Only
Form and Instruction	Survey #4 Provider View of Decision Aid	Survey #4 Provider View of Decision Aid	Survey #4 Provider View of Decision Aid.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 724	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	724	0	0	0	0	0
Annual IC Time Burden (Hours)	171	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Memo	OMBTransLet12-2010.wpd	04/12/2010
Justification	OMB Justification.doc	04/12/2010
Product #1 What is Right for Me Workbook	Product #1 What is Right for Me Workbook.pdf	04/12/2010
Product #2 Supporting Choice Workbook	Product #2 Supporting Choice Workbook.pdf	04/12/2010

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