Information Collection

MMHSA Survey

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.