Information Collection

Program Implementation Survey

IC 239853 under ICR 202206-0906-002 · OMB 0906-0052.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3-1 Program Implementation Survey	Form and Instruction
Form 3-1 PMHCA Program Implementation Survey_2-3-2020.docx Program Implementation Survey	Form and Instruction
Form 3-2 MDRBD Program Implementation Survey_2-3-2020.docx Program Implementation Survey	Form and Instruction
3-1 PMHCA Program Implementation Survey_2-3-2020.docx Attachment B5 - PMHCA Program Implementation Survey_2-3-2020.docx	Form and Instruction
3-1 PMHCA Program Implementation Survey_2-3-2020.docx Attachment B5 - PMHCA Program Implementation Survey_2-3-2020.docx	Form and Instruction
3-2 MDRBD Program Implementation Survey_2-3-2020.docx Attachment B6-MDRBD Program Implementation Survey_2-3-2020.docx	Form and Instruction
3-2 MDRBD Program Implementation Survey_2-3-2020.docx Attachment B6-MDRBD Program Implementation 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	3-1				Yes	Yes	Fillable Fileable
Form and Instruction	3-2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 28

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: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	84	84
Annual IC Time Burden (Hours)	28	28
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.

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