Information Collection

Practice-Level Survey

IC 239852 under ICR 202206-0906-002 · OMB 0906-0052.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2-1 Practice-Level Survey	Form and Instruction
2-1 PMHCA Practice Level Survey_2-3-2020.docx Attachment B3 - PMHCA Practice Level Survey_2-3-2020.docx	Form and Instruction
2-1 PMHCA Practice Level Survey_2-3-2020.docx Attachment B3 - PMHCA Practice Level Survey_2-3-2020.docx	Form and Instruction
2-2 MDRBD Practice Level Survey 2-3-2020.docx Attachment B4-MDRBD Practice Level Survey 2-3-2020.docx	Form and Instruction
2-2 MDRBD Practice Level Survey 2-3-2020.docx Attachment B4-MDRBD Practice Level Survey 2-3-2020.docx	Form and Instruction

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	2-1	PMHCA Practice Level Survey_2-3-2020.docx	Attachment B3 - PMHCA Practice Level Survey_2-3-2020.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2-2	MDRBD Practice Level Survey 2-3-2020.docx	Attachment B4-MDRBD Practice Level Survey 2-3-2020.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,165

Number of Respondents for Small Entity: 4,165

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	12,495	12,495
Annual IC Time Burden (Hours)	3,124	3,124
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.