EBP Self-Assessment Part 1

Evaluation of Programs to Provide Services to Persons Who Are Homeless with Mental and /or Substance Use Disorders

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0339 can be found here:

Documents and Forms

Document Name Document Type
Form EBP Self-Assessmen EBP Self-Assessment Part 1 Form and Instruction
EBP Self-Assessmen EBP Self-Assessment Part 1 and Part 2 Attachment 03_EBP Self-Assessment Part 1 and Part 2.docx Form and Instruction
Attachment 08_EBP Web Consent.docx EBP Web Consent IC Document

Information Collection (IC) Details

IC Title:	EBP Self-Assessment Part 1	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	EBP Self-Assessment Part 1 and Part 2	EBP Self-Assessment Part 1 and Part 2	Attachment 03_EBP Self-Assessment Part 1 and Part 2.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 127	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	127	127
Annual IC Time Burden (Hours)	74	74
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
EBP Web Consent	Attachment 08_EBP Web Consent.docx	08/19/2013

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