Information Collection

Medication-Assisted Treatment (MAT) Application

IC 220719 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⚠️ Notice: This information collection may be referencing outdated material.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 MAT APP Medication-Assisted Treatment (MAT) Application	Form and Instruction
MAT APP MAT APP Attachment 1_MAT App Feedback Survey_03 21 16.KHCdocx.docx	Form and Instruction
MAT App User Feedback Survey OMB Request 03-21-16.KHC.doc Supporting Statement	IC Document
Trans.Let-9-2016.doc Transmittal Letter	IC Document

IC Title:

Medication-Assisted Treatment (MAT) Application

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	MAT APP	MAT APP	Attachment 1_MAT App Feedback Survey_03 21 16.KHCdocx.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 216

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	216	216
Annual IC Time Burden (Hours)	11	11
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	MAT App User Feedback Survey OMB Request 03-21-16.KHC.doc	03/22/2016
Transmittal Letter	Trans.Let-9-2016.doc	03/22/2016

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