Grantee Frontline Staff Survey

Primary and Behavioral Health Care Integration Evaluation

Documents and Forms

Document Name Document Type
Form Staff Survey Grantee Frontline Staff Survey Form and Instruction
Staff Survey Staff Survey Attachment B PBHCI Staff Survey_Updated 9.21.16.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Grantee Frontline Staff 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	Staff Survey	Staff Survey	Attachment B PBHCI Staff Survey_Updated 9.21.16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 782	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	1,494	1,494
Annual IC Time Burden (Hours)	747	747
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.