Clinical Survey Instrument

ASSESSMENT OF CANCER PREVENTION SERVICES AT COMMUNITY MENTAL HEALTH CENTERS

Documents and Forms

Document Name Document Type
Clinical Survey Instrument Form and Instruction
National Survey on Community Mental Health Center Cancer CMHC_OMB_SSA_APPENDIX 4_Survey Instruments_080317.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Clinical Survey Instrument	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	NA	National Survey on Community Mental Health Center Cancer Prevention Activities: Clinician Survey	CMHC_OMB_SSA_APPENDIX 4_Survey Instruments_080317.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	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	500	500
Annual IC Time Burden (Hours)	125	125
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.