EBP Self-Assessment Part 2

Evaluation of Programs to Provide Services to Persons Who Are Homeless with Mental and /or Substance Use Disorders

Documents and Forms

Document Name Document Type
Form Self-Assessment_Pa EBP Self-Assessment Part 2 Form and Instruction
Self-Assessment_Pa Self-Assessment_Part_1_and_2 Attachment 3_EBP_Self-Assessment_Part_1_and_2.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	EBP Self-Assessment Part 2	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Self-Assessment_Part_1_and_2	Self-Assessment_Part_1_and_2	Attachment 3_EBP_Self-Assessment_Part_1_and_2.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	108	21	0	87
Annual IC Time Burden (Hours)	27	0	-17	44
Annual IC Cost Burden (Dollars)	0	0	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.