Information Collection

Public Engagement Platform

IC 216913 under ICR 201406-0930-006 · OMB 0930-0197.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Public Engagement Platform

Agency IC Tracking Number:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.