Information Collection

MMHSA Survey

IC 197385 under ICR 201104-0930-001 · OMB 0930-0326.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form MMHSA Survey MMHSA Survey	Form and Instruction
MMHSA Survey MMHSA Survey Abt-Medicaid Survey Instrument-FNAL 6-14-2011.pdf	Form and Instruction

IC Title:

MMHSA Survey

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	MMHSA Survey	MMHSA Survey	Abt-Medicaid Survey Instrument-FNAL 6-14-2011.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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	51	51
Annual IC Time Burden (Hours)	51	51
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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