Information Collection

Naloxone Safety Net Program

IC 263886 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⚠️ Notice: This information collection may be referencing outdated material.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 0917-0036 Naloxone Safety Net Program Worksheet Naloxone Safety Net Program	Form and Instruction
0917-0036 Naloxone Safety Net Program Worksheet Naloxone Safety Net Program Proposal Request_TA Worksheet.docx	Form and Instruction
Clearance Submission for Naloxone Safety Net Program.docx Clearance Submission Naloxone Program	IC Document

IC Title:

Naloxone Safety Net Program

Agency IC Tracking Number:

142

IC Status: New

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	0917-0036				No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Clearance Submission Naloxone Program		12/12/2023

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

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