Information Collection

Champion and Community Resources SSI

IC 256680 under ICR 202210-0906-004 · OMB 0906-0074.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0074 can be found here:

Documents and Forms

Document Name Document Type
Attachment B5 - PMHCA Champion SSI - Copy.docx Other-Semi Structured Interveiw
Attachment B5 - PMHCA Champion SSI - Copy.docx Other-Semi Structured Interveiw
Attachment B6 - MDRBD Champion SSI - Copy.docx Other-Semi Structured Interview
Attachment B6 - MDRBD Champion SSI - Copy.docx Other-Semi Structured Interview
Attachment B9 - PMHCA Community Resources SSI - Copy.docx Other-Semi Structured Interview
Attachment B9 - PMHCA Community Resources SSI - Copy.docx Other-Semi Structured Interview
Attachment B10 - MDRBD Community Resources SSI - Copy.docx Other-Semi Structured Interview
Attachment B10 - MDRBD Community Resources SSI - Copy.docx Other-Semi Structured Interview

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Champion and Community Resources SSI	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Semi Structured Interveiw	Attachment B5 - PMHCA Champion SSI - Copy.docx	Yes	Yes	Fillable Fileable
Other-Semi Structured Interview	Attachment B6 - MDRBD Champion SSI - Copy.docx	Yes	Yes	Fillable Fileable
Other-Semi Structured Interview	Attachment B9 - PMHCA Community Resources SSI - Copy.docx	Yes	Yes	Fillable Fileable
Other-Semi Structured Interview	Attachment B10 - MDRBD Community Resources SSI - Copy.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 204	Number of Respondents for Small Entity: 106

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	204	204
Annual IC Time Burden (Hours)	102	102
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.