Providers - State/Tribal

Cross-Site Evaluation of the Garrett Lee Smith Memorial Suicide Prevention and Early Intervention Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0286 can be found here:

Documents and Forms

Document Name Document Type
Form Provider Instrumen Providers - State/Tribal Form and Instruction
Provider Instrumen Provider Instruments A3 ST - Provider Instruments.pdf Form and Instruction
A4 ST - Provider Supporting Documents.pdf Provider Supporting Documents IC Document

Information Collection (IC) Details

IC Title:	Providers - State/Tribal	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Provider Instruments	Provider Instruments	A3 ST - Provider Instruments.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 97,972	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	391,888	391,742	146
Annual IC Time Burden (Hours)	17,379	17,269	110
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Provider Supporting Documents	A4 ST - Provider Supporting Documents.pdf	06/02/2010

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