Individual/Family Crisis Counseling Servies Encounter Log

Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0270 can be found here:

Documents and Forms

Document Name Document Type
Form Individual_Family_ Individual/Family Crisis Counseling Servies Encounter Log Form and Instruction
Individual_Family_ Individual_Family_Encounter_Form 3_20_15_Attachment A_Individual_Family_Encounter_Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Individual/Family Crisis Counseling Servies Encounter Log	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	Individual_Family_Encounter_Form	Individual_Family_Encounter_Form	3_20_15_Attachment A_Individual_Family_Encounter_Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	39,200	39,200
Annual IC Time Burden (Hours)	5,096	5,096
Annual IC Cost Burden (Dollars)	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.