Program Implementation Survey

Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access and Screening and Treatment for Maternal Depression and Related Behavioral Disorders Programs Project

⚠️ Notice: This information collection may be referencing outdated material.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 3-1 Program Implementation Survey Form and Instruction
3-1 PMHCA Program Implementation Survey_2-3-2020.docx Attachment B5 - PMHCA Program Implementation Survey_2-3-2020.docx Form and Instruction
3-2 MDRBD Program Implementation Survey_2-3-2020.docx Attachment B6-MDRBD Program Implementation Survey_2-3-2020.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Program Implementation 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	3-1	PMHCA Program Implementation Survey_2-3-2020.docx	Attachment B5 - PMHCA Program Implementation Survey_2-3-2020.docx		Yes	Yes	Fillable Fileable
Form and Instruction	3-2	MDRBD Program Implementation Survey_2-3-2020.docx	Attachment B6-MDRBD Program Implementation 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: 28	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	84	84
Annual IC Time Burden (Hours)	28	28
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.