Client-level interview-Physical Health Indicators

Primary and Behavioral Health Care Integration Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0340 can be found here:

Documents and Forms

Document Name Document Type
Form Physical Health In Client-level interview-Physical Health Indicators Form and Instruction
Physical Health In Physical Health Indicators Attachment 1 Physical Health Indicators 8 12 2014.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Client-level interview-Physical Health Indicators	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	Physical Health Indicators	Physical Health Indicators	Attachment 1 Physical Health Indicators 8 12 2014.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,000	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	28,000	-28,000	56,000
Annual IC Time Burden (Hours)	2,240	-2,427	4,667
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.