Information Collection

Baseline

IC 195854 under ICR 201012-0930-002 · OMB 0930-0320.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0320 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Client Interview_B Baseline	Form
Client Interview_B Client Interview_Baseline 2 Attachment 2_Client Interview_Baseline_3.3.11.doc	Form
1 Attachment 1_SAMHSA Priority Goals.doc SAMHSA Priority Goals	IC Document
5 Attachment 5_Client Interview Script.doc Client Interview Script	IC Document
6 Attachment 6_Client Interview Consent Form.doc Client Interview Consent	IC Document
8 Attachment 8_Privacy Pledge.doc Privacy Pledge	IC Document
9 Attachment 9_ClientDataIRBApproval.pdf Client Data IRB Approval	IC Document

IC Title:

Baseline

Agency IC Tracking Number:

Is this a Common Form? No

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	Client Interview_Baseline	Client Interview_Baseline	2 Attachment 2_Client Interview_Baseline_3.3.11.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,885

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 Agency Discretion
Annual Number of Responses for this IC	5,885	5,885
Annual IC Time Burden (Hours)	1,942	1,942
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SAMHSA Priority Goals	1 Attachment 1_SAMHSA Priority Goals.doc	03/16/2011
Client Interview Script	5 Attachment 5_Client Interview Script.doc	03/16/2011
Client Interview Consent	6 Attachment 6_Client Interview Consent Form.doc	03/16/2011
Privacy Pledge	8 Attachment 8_Privacy Pledge.doc	03/16/2011
Client Data IRB Approval	9 Attachment 9_ClientDataIRBApproval.pdf	03/16/2011

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