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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.