Parents' Night Out Survey

Voluntary Customer Satisfaction Surveys to Implement Executive Order 12862 in the Substance Abuse and Mental Health Services Administration (SAMHSA)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0197 can be found here:

Documents and Forms

Document Name Document Type
Form Parents' Night Out Parents' Night Out Survey Form and Instruction
Parents' Night Out Parents' Night Out Survey Parents_Night_Out_Survey(Attachment B).docx Form and Instruction
PNO_Supplemental_Statement-Justification_Attachment B.docx PNO_Supplemental_Statement-Justification_Attachment B IC Document

Information Collection (IC) Details

IC Title:	Parents' Night Out Survey	Agency IC Tracking Number:

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	Parents' Night Out Survey	Parents' Night Out Survey	Parents_Night_Out_Survey(Attachment B).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Parents' Night Out Survey	FR Citation: 75 FR 28264

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)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
PNO_Supplemental_Statement-Justification_Attachment B	PNO_Supplemental_Statement-Justification_Attachment B.docx	02/22/2021

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