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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.