Information Collection

DBHNA (State/Territory)

IC 197112 under ICR 201103-0930-004 · OMB 0930-0325.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0325 can be found here:

Documents and Forms

Document Name Document Type
Form State/Territory DB DBHNA (State/Territory) Form and Instruction
State/Territory DB State/Territory DBHNAS DTAC_STDBHNAS_060611_FINAL.doc Form and Instruction
A.3 DBHNAS_FINAL.docx DBHNAS-Email Invitation IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	DBHNA (State/Territory)	Agency IC Tracking Number:

Is this a Common Form? No		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	State/Territory DBHNAS	State/Territory DBHNAS	DTAC_STDBHNAS_060611_FINAL.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 77	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 Agency Discretion
Annual Number of Responses for this IC	77	77
Annual IC Time Burden (Hours)	77	77
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
DBHNAS-Email Invitation	A.3 DBHNAS_FINAL.docx	03/29/2011

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