Information Collection

Phase 2 Behavioral Survey

IC 218947 under ICR 201811-0920-002 · OMB 0920-1100.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1100 can be found here:

Documents and Forms

Document Name Document Type
Phase 2 Behavioral Survey Form and Instruction
Phase 2 Behavioral Survey (English) Att 8a_Phase 2 Behavioral Survey (English).docx Form and Instruction
Phase 2 Behavioral Survey (Spanish) Att 8b_Phase 2 Behavioral Survey (Spanish).docx Form and Instruction
Phase 2 Behavioral Survey (screen shots in Spanish) Att 12b_Screenshots_Phase 2 Behavioral Survey (Spanish).pdf Form and Instruction
Phase 2 Behavioral Survey (screen shots in English) Att 12a_Screenshots_Phase 2 Behavioral Survey.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Phase 2 Behavioral Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Phase 2 Behavioral Survey (English)	Att 8a_Phase 2 Behavioral Survey (English).docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Phase 2 Behavioral Survey (Spanish)	Att 8b_Phase 2 Behavioral Survey (Spanish).docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Phase 2 Behavioral Survey (screen shots in Spanish)	Att 12b_Screenshots_Phase 2 Behavioral Survey (Spanish).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Phase 2 Behavioral Survey (screen shots in English)	Att 12a_Screenshots_Phase 2 Behavioral Survey.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	25	25
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.