Client questionnaire - 12 month follow-up

Evaluation of Medication- Assisted Treatment (MAT) for Opioid Use Disorders Study

Documents and Forms

Document Name Document Type
Client questionnaire - 12 month follow-up Form
Client questionnaire - 12 month follow up - Spanish Attachment 6 Client Questionnaire baseline 12 24 months__09_27_17_spanish.docx Form
Client questionnaire - 12 month follow up - Spanish Attachment 6 Client Questionnaire baseline 12 24 months__09_27_17_spanish.docx Form
Client questionnaire - 12 month follow-up - English Attachment 6 Client Questionnaire baseline 12 24 months_9_27_17 17ACE_MAT.docx Form
Client questionnaire - 12 month follow-up - English Attachment 6 Client Questionnaire baseline 12 24 months_9_27_17 17ACE_MAT.docx Form

Information Collection (IC) Details

IC Title:	Client questionnaire - 12 month follow-up	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	none	Client questionnaire - 12 month follow up - Spanish	Attachment 6 Client Questionnaire baseline 12 24 months__09_27_17_spanish.docx		Yes	Yes	Fillable Fileable
Form	none	Client questionnaire - 12 month follow-up - English	Attachment 6 Client Questionnaire baseline 12 24 months_9_27_17 17ACE_MAT.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 930	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-930	930
Annual IC Time Burden (Hours)	-698	698
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.