Project EVOLVE Feedback Survey

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⚠️ Notice: This information collection may be referencing outdated material.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 Feedback Survey Project EVOLVE Feedback Survey Form and Instruction
Feedback Survey Feedback Survey SurveyMonkeyQuestions.jpg Form and Instruction
SAMHSA Customer Satisfaction Survey-EVOLVE 6.13.13.docx Justification IC Document
Trans.Let-8-2012.doc Letter IC Document

Information Collection (IC) Details

IC Title:	Project EVOLVE Feedback Survey	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	Feedback Survey	Feedback Survey	SurveyMonkeyQuestions.jpg		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 700	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	700	0	0	0	0	0
Annual IC Time Burden (Hours)	56	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Justification	SAMHSA Customer Satisfaction Survey-EVOLVE 6.13.13.docx	05/13/2013
Letter	Trans.Let-8-2012.doc	05/13/2013

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