Information Collection

User Survey for In-Home Drug Deactivation System - State and Local

IC 217785 under ICR 201503-0925-007 · OMB 0925-0655.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Home User Survey User Survey for In-Home Drug Deactivation System - State and Local	Form and Instruction
Form 2 Provider Survey User Survey for In-Home Drug Deactivation System - State and Local	Form and Instruction
1 Home User Survey Home User Survey - Screenshot 06192015.pdf	Form and Instruction
2 Provider Survey Providers Survey - Screenshot 06192015.pdf	Form and Instruction
2015 Fast Track Template - Police- 0728015.doc Fast Track Submission Form	IC Document

IC Title:

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	1				Yes	Yes	Fillable Fileable
Form and Instruction	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	50	50
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Submission Form		08/05/2015

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

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