Information Collection

Individual/Family Crisis Counseling Services Encounter Log

IC 7686 under ICR 202206-0930-002 · OMB 0930-0270.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0270 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Individual/Family Individual/Family Crisis Counseling Services Encounter Log	Form and Instruction
Individual/Family Individual/Family Services Encounter Log -Att-A-IndividualFamily-508-OMB2022_2022-01-11 _ clean.pdf	Form and Instruction
Individual/Family Individual/Family Services Encounter Log -Att-A-IndividualFamily-508-OMB2022_2022-01-11 _ clean.pdf	Form and Instruction

IC Title:

Individual/Family Crisis Counseling Services Encounter Log

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Individual/Family Services Encounter Log	Individual/Family Services Encounter Log	-Att-A-IndividualFamily-508-OMB2022_2022-01-11 _ clean.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Individual/Family Crisis Counseling Services Encounter Log

FR Citation: 75 FR 28264

Number of Respondents: 1,500

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
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	285,000	167,400	117,600
Annual IC Time Burden (Hours)	22,800	13,392	9,408
Annual IC Cost Burden (Dollars)	0	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.