BHIT Survey

Behavioral Health Information Technologies Survey

Documents and Forms

Document Name Document Type
Form BHITS BHIT Survey Form and Instruction
BHITS BHITS Attachment 1_Survey Questions_05_28_15.docx Form and Instruction
Attachment 2_Data Dictionary-Key-Terms-Definitions_2_27_15.docx Data Dictionary IC Document
Attachment 3_Survey Question Crosswalk to Research Question and Domain_052215.docx Survey Question Crosswalk IC Document
Attachment 4_Pilot_Protocol_Schedule_Documents-2_27_15.docx Pilot_Protocol IC Document
Attachment 5_GranteeLetter_2_27_15.doc Grantee Letter IC Document
Attachment 6_ScrennShots._5_27_15pdf Screnn Shots IC Document

Information Collection (IC) Details

IC Title:	BHIT Survey	Agency IC Tracking Number:

Is this a Common Form? No		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	BHITS	BHITS	Attachment 1_Survey Questions_05_28_15.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 374	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	374	374
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Data Dictionary	Attachment 2_Data Dictionary-Key-Terms-Definitions_2_27_15.docx	05/28/2015
Survey Question Crosswalk	Attachment 3_Survey Question Crosswalk to Research Question and Domain_052215.docx	05/28/2015
Pilot_Protocol	Attachment 4_Pilot_Protocol_Schedule_Documents-2_27_15.docx	05/28/2015
Grantee Letter	Attachment 5_GranteeLetter_2_27_15.doc	05/28/2015
Screnn Shots	Attachment 6_ScrennShots._5_27_15pdf	05/28/2015

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