Medication-Assisted Treatment (MAT) Application

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⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

IC Title:	Medication-Assisted Treatment (MAT) Application	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	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 %

	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

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.