Information Collection

NHSC Comprehensive Behavioral Health Services Checklist

IC 225046 under ICR 201701-0915-003 · OMB 0915-0127.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0127 can be found here:

Documents and Forms

Document Name Document Type
Form 6 NHSC Comprehensive Behavioral Health Services Checklist Form and Instruction
6 NHSC Behavioral Health Checklist NHSC Behavioral Health Checklist.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NHSC Comprehensive Behavioral Health Services Checklist	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	6	NHSC Behavioral Health Checklist	NHSC Behavioral Health Checklist.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	520	520
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.