Information Collection

State and Territory Survey

IC 217164 under ICR 201506-0990-003 · OMB 0990-0441.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-OMH Attachment B - Interview Topics and Data Collection Tables Handout 7-31-15 final.docx	Other-survey
0990-Attachment A - OMH State and Territorial Survey final Edits.61915.docx	Other-survey
0990 OMH Attachment C - Technical Expert Panel Membership Roster.JNG Edits 6915.docx Attachment C	IC Document
0990-OMH_Attachment D - Introductory Letters.61915 final.docx Introductory letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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
Other-survey			0990-OMH Attachment B - Interview Topics and Data Collection Tables Handout 7-31-15 final.docx		No		Fillable Printable
Other-survey			0990-Attachment A - OMH State and Territorial Survey final Edits.61915.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	54	54
Annual IC Time Burden (Hours)	81	81
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C	0990 OMH Attachment C - Technical Expert Panel Membership Roster.JNG Edits 6915.docx	10/20/2015
Introductory letter	0990-OMH_Attachment D - Introductory Letters.61915 final.docx	10/20/2015

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