Information Collection

DBHNAS (Local Provider)

IC 197111 under ICR 201403-0930-006 · OMB 0930-0325.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0325 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Local Provider DBHNAS (Local Provider)	Form and Instruction
Local Provider Local Provider Attachment A2 Local Provider NAS.docx	Form and Instruction

IC Title:

DBHNAS (Local Provider)

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	Local Provider	Local Provider	Attachment A2 Local Provider NAS.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

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	150	50	100
Annual IC Time Burden (Hours)	75	25	50
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.