Information Collection

Client-Level

IC 46632 under ICR 201612-0930-003 · OMB 0930-0285.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0285 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Adult Tool with Re Client-Level	Form and Instruction
Adult Tool with Re AdultTool with Recovery Measures CMHS SVCS AdultTool with Recovery Measures 9-9-16 FINAL.docx	Form and Instruction
Child Combined Too Child Combined Tool SVCS_ChildCombinedTool_11.19.13.docx	Form and Instruction

IC Title:

Client-Level

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	Adult Tool with Recovery Measures	AdultTool with Recovery Measures	CMHS SVCS AdultTool with Recovery Measures 9-9-16 FINAL.docx		Yes	Yes	Fillable Fileable
Form and Instruction	Child Combined Tool	Child Combined Tool	SVCS_ChildCombinedTool_11.19.13.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 144,954

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	144,954	46,806	98,148
Annual IC Time Burden (Hours)	70,240	36,281	33,959
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.