Information Collection

e-Communications Recipient

IC 197113 under ICR 201610-0930-003 · OMB 0930-0325.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SAMHSA DTAC CFS e-Communications Recipient	Form and Instruction
SAMHSA DTAC CFS SAMHSA DTAC CFS Attachment 1 SAMHSA DTAC CFS _6.27.16.docx	Form and Instruction

IC Title:

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	SAMHSA DTAC CFS	SAMHSA DTAC CFS	Attachment 1 SAMHSA DTAC CFS _6.27.16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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	200	-100	300
Annual IC Time Burden (Hours)	100	25	75
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.