Information Collection

Behavioral Health Providers/Stakeholders - State/Tribal

IC 208304 under ICR 201512-0930-006 · OMB 0930-0286.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0286 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form BHPS StateTribal Behavioral Health Providers/Stakeholders - State/Tribal	Form and Instruction
BHPS StateTribal BHPS StateTribal Att J. BHPS StateTribal Dec2015.docx	Form and Instruction
RNS StateTribal RNS StateTribal Att K. RNS (StateTribal) Dec2015.docx	Form and Instruction

IC Title:

Behavioral Health Providers/Stakeholders - State/Tribal

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	BHPS StateTribal	BHPS StateTribal	Att J. BHPS StateTribal Dec2015.docx		Yes	Yes	Fillable Fileable
Form and Instruction	RNS StateTribal	RNS StateTribal	Att K. RNS (StateTribal) Dec2015.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 433

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	Previously Approved
Annual Number of Responses for this IC	433	-1,419	1,852
Annual IC Time Burden (Hours)	322	-920	1,242
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.