Information Collection

Structured Interview Questionnaire

IC 210727 under ICR 201403-0930-004 · OMB 0930-0341.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Peer Support Servi Structured Interview Questionnaire	Form and Instruction
Peer Support Servi Peer Support Services Interview PeerSupportServices_SurveyRevision_V7_.docx	Form and Instruction
Telephone script_PRSS_v5_.docx Telephone script	IC Document

IC Title:

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	Peer Support Services Interview	Peer Support Services Interview	PeerSupportServices_SurveyRevision_V7_.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	40	40
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Telephone script	Telephone script_PRSS_v5_.docx	03/05/2014

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