SMI Clients

Primary and Behavioral Health Care Integration Evaluation

Documents and Forms

Document Name Document Type
Form Client Health Asse SMI Clients Form and Instruction
Client Health Asse Client Health Assessment Questionnaire Attachment L Client Health Assessment Questionnaire_FINAL DRAFT FOR OMB.docx Form and Instruction

Information Collection (IC) Details

IC Title:	SMI Clients	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	Client Health Assessment Questionnaire	Client Health Assessment Questionnaire	Attachment L Client Health Assessment Questionnaire_FINAL DRAFT FOR OMB.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,250	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	4,250	4,250
Annual IC Time Burden (Hours)	4,250	4,250
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.