Information Collection

SAMHSA Checklist for SF-5161

IC 180307 under ICR 201705-0930-001 · OMB 0930-0367.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Checklist SF-5161 Checklist SF-5161 SAMHSA Checklist for SF-5161	Form and Instruction
Checklist SF-5161 Checklist SF-5161 Attachment A SF_5161-Chcklist_2.7.17.pdf	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	Checklist SF-5161				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,669

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	2,669	-4,788	7,457
Annual IC Time Burden (Hours)	801	-19,129	19,930
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.

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