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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

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.