Information Collection

Program Implmentation Semi-Structured Interview

IC 239854 under ICR 202206-0906-002 · OMB 0906-0052.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4-1 Program Implmentation Semi-Structured Interview	Form and Instruction
4-1 PMHCA Program Implementation SSI Guide_2-3-2020.docx Attachment B7 - PMHCA Program Implementation SSI Guide_2-3-2020.docx	Form and Instruction
4-1 PMHCA Program Implementation SSI Guide_2-3-2020.docx Attachment B7 - PMHCA Program Implementation SSI Guide_2-3-2020.docx	Form and Instruction
4-2 MDRBD Program Implementation SSI Guide_2-3-2020.docx Attachment B8-MDRBD Program Implementation SSI Guide_2-3-2020.docx	Form and Instruction
4-2 MDRBD Program Implementation SSI Guide_2-3-2020.docx Attachment B8-MDRBD Program Implementation SSI Guide_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	4-1	PMHCA Program Implementation SSI Guide_2-3-2020.docx	Attachment B7 - PMHCA Program Implementation SSI Guide_2-3-2020.docx		Yes	Yes	Fillable Fileable
Form and Instruction	4-2	MDRBD Program Implementation SSI Guide_2-3-2020.docx	Attachment B8-MDRBD Program Implementation SSI Guide_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: 28

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	28	28
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.