Information Collection

Individual/Family Crisis Counseling Servies Encounter Log

IC 7686 under ICR 201901-0930-004 · OMB 0930-0270.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0270 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Individual/Family Individual/Family Crisis Counseling Servies Encounter Log	Form
Individual/Family Individual/Family Encounter Log Attachment A-IndividualFamilyEncounterForm-Rev.pdf	Form
Group Encounter Lo Group Encounter Log Attachment B-GroupEncounterLog-Rev.pdf	Form
Weekly Tally Sheet Weekly Talkly Sheet Attachment C-WeeklyTallySheet-Rev.pdf	Form
Adult Assessment a Adult Assessment and Referral Tool Attachment D-AdultAssessmentandReferralTool-Rev.pdf	Form
Child/YOuth Assess Child/YOuth Assessment and Referral Tool Attachment E-ChildYouthAssessmentandReferralTool-Rev.pdf	Form
Service Provider F Service Provider Feedback Form Attachment G-ServiceProviderFeedbackForm-Rev.pdf	Form

IC Title:

Individual/Family Crisis Counseling Servies Encounter Log

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Individual/Family Encounter Log	Individual/Family Encounter Log	Attachment A-IndividualFamilyEncounterForm-Rev.pdf	Yes	Yes	Fillable Fileable Signable
Form	Group Encounter Log	Group Encounter Log	Attachment B-GroupEncounterLog-Rev.pdf	Yes	Yes	Fillable Fileable
Form	Weekly Tally Sheet	Weekly Talkly Sheet	Attachment C-WeeklyTallySheet-Rev.pdf	Yes	Yes	Fillable Fileable
Form	Adult Assessment and Referral Tool	Adult Assessment and Referral Tool	Attachment D-AdultAssessmentandReferralTool-Rev.pdf	Yes	Yes	Fillable Fileable
Form	Child/YOuth Assessment and Referral Tool	Child/YOuth Assessment and Referral Tool	Attachment E-ChildYouthAssessmentandReferralTool-Rev.pdf	Yes	Yes	Fillable Fileable
Form	Service Provider Feedback Form	Service Provider Feedback Form	Attachment G-ServiceProviderFeedbackForm-Rev.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	117,600	117,600
Annual IC Time Burden (Hours)	9,408	9,408
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.