Public Engagement Platform

Voluntary Customer Satisfaction Surveys to Implement Executive Order 12862 in the Substance Abuse and Mental Health Services Administration (SAMHSA)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0197 can be found here:

Documents and Forms

Document Name Document Type
Form Survey Public Engagement Platform Form and Instruction
Survey Survey SAMHSA Customer Feedback Survey OMB Request REVISED 5.28.15.doc Form and Instruction
SAMHSA Customer Feedback Survey OMB Request Attachment REVISED 5.28.15.doc Justification IC Document
Trans.Let-5-2014.doc Letter IC Document

Information Collection (IC) Details

IC Title:	Public Engagement Platform	Agency IC Tracking Number:

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	Survey	Survey	SAMHSA Customer Feedback Survey OMB Request REVISED 5.28.15.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	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	600	600
Annual IC Time Burden (Hours)	48	48
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Justification	SAMHSA Customer Feedback Survey OMB Request Attachment REVISED 5.28.15.doc	06/08/2015
Letter	Trans.Let-5-2014.doc	06/08/2015

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