Information Collection

Practice-Level Survey

IC 239852 under ICR 202002-0906-001 · OMB 0906-0052.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0052 can be found here:

Documents and Forms

Document Name Document Type
Form 2-1 Practice-Level Survey Form and Instruction
2-1 PMHCA Practice Level Survey_2-3-2020.docx Attachment B3 - PMHCA Practice Level Survey_2-3-2020.docx Form and Instruction
2-2 MDRBD Practice Level Survey 2-3-2020.docx Attachment B4-MDRBD Practice Level Survey 2-3-2020.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Practice-Level Survey	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	2-1	PMHCA Practice Level Survey_2-3-2020.docx	Attachment B3 - PMHCA Practice Level Survey_2-3-2020.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2-2	MDRBD Practice Level Survey 2-3-2020.docx	Attachment B4-MDRBD Practice Level Survey 2-3-2020.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,165	Number of Respondents for Small Entity: 4,165

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12,495	12,495
Annual IC Time Burden (Hours)	3,124	3,124
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.