Provider - State/Tribal - Stakeholder

Cross-Site Evaluation of the Garrett Lee Smith Memorial Suicide Prevention and Early Intervention Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0286 can be found here:

Documents and Forms

Document Name Document Type
Form E. RNS Instrument Provider - State/Tribal - Stakeholder Form and Instruction
E. RNS Instrument E. RNS Instrument and Verbal Consent Script.docx E. RNS Instrument and Verbal Consent Script.docx Form and Instruction
G. Coalition Surve G. Coalition Survey Instrument and Web Consent.docx G. Coalition Survey Instrument and Web Consent.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Provider - State/Tribal - Stakeholder	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	E. RNS Instrument and Verbal Consent Script.docx	E. RNS Instrument and Verbal Consent Script.docx	E. RNS Instrument and Verbal Consent Script.docx		Yes	Yes	Fillable Fileable
Form and Instruction	G. Coalition Survey Instrument and Web Consent	G. Coalition Survey Instrument and Web Consent.docx	G. Coalition Survey Instrument and Web Consent.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,852	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,852	1,852
Annual IC Time Burden (Hours)	1,242	1,242
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.