Information Collection

Individual/Family Crisis Counseling Servies Encounter Log

IC 7686 under ICR 201203-0930-002 · OMB 0930-0270.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0270 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Individual/Family Crisis Counseling Servies Encounter Log	Form and Instruction
Individual Family Encounter Form Attachment_A_IndividualFamilyEncounterForm 7.31.12.docx	Form and Instruction
Attachment I_Response to CommentsFINAL.docx Response to Comments	IC Document
Attachment H Public Comments Received.docx Public Comments Received	IC Document

IC Title:

Individual/Family Crisis Counseling Servies Encounter Log

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	N/A	Individual Family Encounter Form	Attachment_A_IndividualFamilyEncounterForm 7.31.12.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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	Previously Approved
Annual Number of Responses for this IC	39,200	-89,200	128,400
Annual IC Time Burden (Hours)	5,096	-7,201	12,297
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Response to Comments	Attachment I_Response to CommentsFINAL.docx	02/17/2012
Public Comments Received	Attachment H Public Comments Received.docx	02/17/2012

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