Information Collection

Assessing State Programs' Community-Clinical Linkages and Related Technical Assistance Needs

IC 200759 under ICR 201008-0920-003 · OMB 0920-0864.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Assessing State Programs' Community-Clinical Linkages and Related Technical Assistance Needs	Form
Assessing Community-Clinical Linkages Attachment 1_NHDSP Survey Screenshots.pdf	Form
0920-0864_IC 5_SS A_1 09 2012.docx Supporting Statement A	IC Document
0920-0864_IC 5_SS B_1 09 2012.docx Supporting Statement B	IC Document
Attachment 2_NHDSP Introductory Email.docx Intro email	IC Document
Attachment 3_NHDSP Invitation Email.docx Invitation email	IC Document
Attachment 4_NHDSP Reminder Email.docx Reminder email	IC Document
Attachment 5_NHDSP Thank You Email.docx Thank you email	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Assessing Community-Clinical Linkages	Attachment 1_NHDSP Survey Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	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	51	0	0	0	0	0
Annual IC Time Burden (Hours)	21	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	0920-0864_IC 5_SS A_1 09 2012.docx	01/09/2012
Supporting Statement B	0920-0864_IC 5_SS B_1 09 2012.docx	01/09/2012
Intro email	Attachment 2_NHDSP Introductory Email.docx	01/09/2012
Invitation email	Attachment 3_NHDSP Invitation Email.docx	01/09/2012
Reminder email	Attachment 4_NHDSP Reminder Email.docx	01/09/2012
Thank you email	Attachment 5_NHDSP Thank You Email.docx	01/09/2012

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