Information Collection

Evaluating the Applicability and Use of The Commmunity Guide among SAMHSA Grantees

IC 225311 under ICR 201606-0920-007 · OMB 0920-0974.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Evaluating the Applicability and Use of The Commmunity Guide among SAMHSA Grantees	Form
SAMHSA Grantees Survey SAMHSA Grantees survey 1-23-2017.pdf	Form
Provide Feedback on The Community Guide invitation email script (SAMHSA) 1-13-17.docx Email Invitation	IC Document
Provide Feedback on The Community Guide follow-up email script (SAMHSA) 1-13-17.docx Follow-up Email	IC Document
Screenshot of Survey page 1a.PNG Survey page 1a	IC Document
Screenshot of SAMHSA Survey page 1b.PNG Survey page 1b	IC Document
Screenshot of SAMHSA Survey page 2.PNG Survey page 2	IC Document
Screenshot of SAMHSA Survey page 3.PNG Survey page 3	IC Document
Screenshot of SAMHSA Survey page 4.PNG Survey page 4	IC Document
Screenshot of SAMHSA Survey page 5.PNG Survey page 5	IC Document
Screenshot of SAMHSA Survey page 6.PNG Survey page 6	IC Document
Screenshot of SAMHSA Survey page 7.PNG Survey page 7	IC Document
Screenshot of SAMHSA Survey page 8.PNG Survey page 8	IC Document
Screenshot of SAMHSA Survey page 9.PNG Survey page 9	IC Document
Screenshot of SAMHSA Survey page 10.PNG Survey page 10	IC Document
Screenshot of SAMHSA Survey page 11.PNG Survey page 11	IC Document
Screenshot of SAMHSA Survey page 12.PNG Survey page 12	IC Document
Screenshot of SAMHSA Survey page 13.PNG Survey page 13	IC Document
Fast_Track_GenIC_Request CGB Customer feedback SAMHSA grantees 1-26-17.docx Request for Approval	IC Document

IC Title:

Agency IC Tracking Number:

17NQ

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
Form	none	SAMHSA Grantees Survey	SAMHSA Grantees survey 1-23-2017.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 255

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
Annual Number of Responses for this IC	255	255
Annual IC Time Burden (Hours)	64	64
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Email Invitation	Provide Feedback on The Community Guide invitation email script (SAMHSA) 1-13-17.docx	01/25/2017
Follow-up Email	Provide Feedback on The Community Guide follow-up email script (SAMHSA) 1-13-17.docx	01/25/2017
Survey page 1a	Screenshot of Survey page 1a.PNG	01/25/2017
Survey page 1b	Screenshot of SAMHSA Survey page 1b.PNG	01/25/2017
Survey page 2	Screenshot of SAMHSA Survey page 2.PNG	01/25/2017
Survey page 3	Screenshot of SAMHSA Survey page 3.PNG	01/25/2017
Survey page 4	Screenshot of SAMHSA Survey page 4.PNG	01/25/2017
Survey page 5	Screenshot of SAMHSA Survey page 5.PNG	01/25/2017
Survey page 6	Screenshot of SAMHSA Survey page 6.PNG	01/25/2017
Survey page 7	Screenshot of SAMHSA Survey page 7.PNG	01/25/2017
Survey page 8	Screenshot of SAMHSA Survey page 8.PNG	01/25/2017
Survey page 9	Screenshot of SAMHSA Survey page 9.PNG	01/25/2017
Survey page 10	Screenshot of SAMHSA Survey page 10.PNG	01/25/2017
Survey page 11	Screenshot of SAMHSA Survey page 11.PNG	01/25/2017
Survey page 12	Screenshot of SAMHSA Survey page 12.PNG	01/25/2017
Survey page 13	Screenshot of SAMHSA Survey page 13.PNG	01/25/2017
Request for Approval	Fast_Track_GenIC_Request CGB Customer feedback SAMHSA grantees 1-26-17.docx	01/31/2017

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