Mid-Course technical Assistance Feedback Form

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⚠️ Notice: This information collection may be referencing outdated material.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 Mid-Course Feedbac Mid-Course technical Assistance Feedback Form Form and Instruction
Mid-Course Feedbac Mid-Course Feedback Form Attachment 1 Mid Course Feedback Form.docx Form and Instruction
Technical Assistance Enterprise, Mid-Course Feedback Form, 5.4.12.doc Justification IC Document
Trans.Let-2-2012.doc Transmit Letter IC Document

Information Collection (IC) Details

IC Title:	Mid-Course technical Assistance Feedback Form	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	Mid-Course Feedback Form	Mid-Course Feedback Form	Attachment 1 Mid Course Feedback Form.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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	100	0	0	0	0	0
Annual IC Time Burden (Hours)	20	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Justification	Technical Assistance Enterprise, Mid-Course Feedback Form, 5.4.12.doc	05/04/2012
Transmit Letter	Trans.Let-2-2012.doc	05/04/2012

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