Information Collection

Program Staff Questionnaires (Form M-11A-K) - Recordkeeping

IC 245605 under ICR 202112-0970-003 · OMB 0970-0564.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0564 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form M-11A Program Staff Questionnaires (Form M-11A-K) - Recordkeeping	Form and Instruction
Form M-11A Program Director Questionnaire Program Director Questionnaire (Form M-11A).docx	Form and Instruction
Form M-11A Program Director Questionnaire Program Director Questionnaire (Form M-11A).docx	Form and Instruction
Form M-11B LTFC Program Director Questionnaire LTFC Program Director Questionnaire (Form M-11B).docx	Form and Instruction
Form M-11B LTFC Program Director Questionnaire LTFC Program Director Questionnaire (Form M-11B).docx	Form and Instruction
Form M-11C Clinician Questionnaire Clinician Questionnaire (Form M-11C).docx	Form and Instruction
Form M-11C Clinician Questionnaire Clinician Questionnaire (Form M-11C).docx	Form and Instruction
Form M-11D LTFC Clinician Questionnaire LTFC Clinician Questionnaire (Form M-11D).docx	Form and Instruction
Form M-11D LTFC Clinician Questionnaire LTFC Clinician Questionnaire (Form M-11D).docx	Form and Instruction
Form M-11E Case Manager Questionnaire Case Manager Questionnaire (Form M-11E).docx	Form and Instruction
Form M-11E Case Manager Questionnaire Case Manager Questionnaire (Form M-11E).docx	Form and Instruction
Form M-11F LTFC Case Manager Questionnaire LTFC Case Manager Questionnaire (Form M-11F).docx	Form and Instruction
Form M-11F LTFC Case Manager Questionnaire LTFC Case Manager Questionnaire (Form M-11F).docx	Form and Instruction
Form M-11G Education Staff Questionnaire Education Staff Questionnaire (Form M-11G).docx	Form and Instruction
Form M-11G Education Staff Questionnaire Education Staff Questionnaire (Form M-11G).docx	Form and Instruction
Form M-11H LTFC Educational Staff Questionnaire LTFC Educational Staff Questionnaire (Form M-11H).docx	Form and Instruction
Form M-11H LTFC Educational Staff Questionnaire LTFC Educational Staff Questionnaire (Form M-11H).docx	Form and Instruction
Form M-11I Medical Coordinator Questionnaire Medical Coordinator Questionnaire (Form M-11I).docx	Form and Instruction
Form M-11I Medical Coordinator Questionnaire Medical Coordinator Questionnaire (Form M-11I).docx	Form and Instruction
Form M-11J Youth Care Worker Questionnaire Youth Care Worker Questionnaire (Form M-11J).docx	Form and Instruction
Form M-11J Youth Care Worker Questionnaire Youth Care Worker Questionnaire (Form M-11J).docx	Form and Instruction
Form M-11K PSA Compliance Manager Questionnaire PSA Compliance Manager Questionnaire (Form M-11K).docx	Form and Instruction
Form M-11K PSA Compliance Manager Questionnaire PSA Compliance Manager Questionnaire (Form M-11K).docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Program Staff Questionnaires (Form M-11A-K) - Recordkeeping

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form M-11A	Program Director Questionnaire	Program Director Questionnaire (Form M-11A).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11B	LTFC Program Director Questionnaire	LTFC Program Director Questionnaire (Form M-11B).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11C	Clinician Questionnaire	Clinician Questionnaire (Form M-11C).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11D	LTFC Clinician Questionnaire	LTFC Clinician Questionnaire (Form M-11D).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11E	Case Manager Questionnaire	Case Manager Questionnaire (Form M-11E).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11F	LTFC Case Manager Questionnaire	LTFC Case Manager Questionnaire (Form M-11F).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11G	Education Staff Questionnaire	Education Staff Questionnaire (Form M-11G).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11H	LTFC Educational Staff Questionnaire	LTFC Educational Staff Questionnaire (Form M-11H).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11I	Medical Coordinator Questionnaire	Medical Coordinator Questionnaire (Form M-11I).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11J	Youth Care Worker Questionnaire	Youth Care Worker Questionnaire (Form M-11J).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11K	PSA Compliance Manager Questionnaire	PSA Compliance Manager Questionnaire (Form M-11K).docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	216	216
Annual IC Time Burden (Hours)	216	216
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.