Key Informant Selection Tool

Evaluation of the SAMHSA Naloxone Education and Distribution Program

Documents and Forms

Document Name Document Type
Key Informant Selection Tool Form
Key Informant Selection Tool Att_G_Key Informant Selection Tool_3.29.17.docx Form

Information Collection (IC) Details

IC Title:	Key Informant Selection Tool	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	none	Key Informant Selection Tool	Att_G_Key Informant Selection Tool_3.29.17.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	3	3
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.