Interviews

Testing of Electronic Health Records Questions for the National Survey of Substance Abuse Treatment Services (N-SSATS) and the National Mental Health Services Survey (N-MHSS)

Documents and Forms

Document Name Document Type
Form EHR Questionnaire Interviews Form and Instruction
EHR Questionnaire EHR Questionnaire Attachment A EHR Questionnaire.pdf Form and Instruction
Attachment B Consent Form v_5-7-18_FINAL.DOCX Consent Form IC Document

Information Collection (IC) Details

IC Title:	Interviews	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	EHR Questionnaire	EHR Questionnaire	Attachment A EHR Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	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	80	80
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Consent Form	Attachment B Consent Form v_5-7-18_FINAL.DOCX	10/02/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.