State Survey - Baseline

State Targeted Response to the Opioid Crisis (Opioid STR) Evaluation

Documents and Forms

Document Name Document Type
Form State Director Bas State Survey - Baseline Form and Instruction
State Director Bas State Director Baseline Survey Attachment 1. Opioid STR State Director Baseline Survey 7.5.17.docx Form and Instruction

Information Collection (IC) Details

IC Title:	State Survey - Baseline	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	State Director Baseline Survey	State Director Baseline Survey	Attachment 1. Opioid STR State Director Baseline Survey 7.5.17.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 57	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
Annual Number of Responses for this IC	57	57
Annual IC Time Burden (Hours)	228	228
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.