State Survey - Time 3

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

Documents and Forms

Document Name Document Type
Form State Director Tim State Survey - Time 3 Form and Instruction
State Director Tim State Director Time 3 Survey Attachment 3. Opioid STR State Director Final Survey 7.5.17.docx Form and Instruction

Information Collection (IC) Details

IC Title:	State Survey - Time 3	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 Time 3 Survey	State Director Time 3 Survey	Attachment 3. Opioid STR State Director Final 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.