Information Collection

Tele-Behavioral Health Center of Excellence (TBHCE) Survey

IC 236408 under ICR 202201-0917-001 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 9017-0036 Tele-Behavioral Health Center of Excellence (TBHCE) Survey	Form and Instruction
9017-0036 LHP Behaviorial Health Training Needs Survey Licensed Healthcare Professional Behavioral Health Training Needs Survey 6.6.2019.docx	Form and Instruction
9017-0036 LHP Behaviorial Health Training Needs Survey Licensed Healthcare Professional Behavioral Health Training Needs Survey 6.6.2019.docx	Form and Instruction
2015 Generic Clearance Submission Template - 6.10.19.doc Generic Clearance Submission - BH Surveys	IC Document
2015 Generic Clearance Submission Template - 6.10.19.doc Generic Clearance Submission - BH Surveys	IC Document

IC Title:

Tele-Behavioral Health Center of Excellence (TBHCE) Survey

Agency IC Tracking Number:

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	9017-0036	LHP Behaviorial Health Training Needs Survey	Licensed Healthcare Professional Behavioral Health Training Needs Survey 6.6.2019.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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
	Requested	Previously Approved
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Clearance Submission - BH Surveys	2015 Generic Clearance Submission Template - 6.10.19.doc	06/10/2019

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