Information Collection

2021 Survey of Behavioral Health Workforce Providers

IC 246779 under ICR 202110-0930-003 · OMB 0930-0387.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Provider Survey Qu 2021 Survey of Behavioral Health Workforce Providers	Form and Instruction
Provider Survey Qu Provider Survey Questionnaire 7/21/2021 Survey Provider_Clean_OMB_FINAL.docx	Form and Instruction
Provider Survey Qu Provider Survey Questionnaire 7/21/2021 Survey Provider_Clean_OMB_FINAL.docx	Form and Instruction
08B ProviderSurvey_ICF.docx ProviderSurvey_ICF	IC Document
08B ProviderSurvey_ICF.docx ProviderSurvey_ICF	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Provider Survey Questionnaire 7/21/2021	Provider Survey Questionnaire 7/21/2021	Survey Provider_Clean_OMB_FINAL.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 2021 Survey of Behavioral Health Workforce Providers

FR Citation: 75 FR 28264

Number of Respondents: 5,000

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	Previously Approved
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	1,250	1,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ProviderSurvey_ICF	08B ProviderSurvey_ICF.docx	04/13/2021

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