Annual and Quarterly Benchmark Data Collection Form

National Center of Excellence for Infant and Early Childhood Mental Health Consultation

Documents and Forms

Document Name Document Type
Form Annual Quarterly B Annual and Quarterly Benchmark Data Collection Form Form and Instruction
Annual Quarterly B Annual Quarterly Benchmark Data Collection Forms IECMHC_Attachment F_Annual Quarterly Benchmark Data Collection Forms_2-10-16.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Annual and Quarterly Benchmark Data Collection Form	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	Annual Quarterly Benchmark Data Collection Forms	Annual Quarterly Benchmark Data Collection Forms	IECMHC_Attachment F_Annual Quarterly Benchmark Data Collection Forms_2-10-16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17	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	68	68
Annual IC Time Burden (Hours)	102	102
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.