Information Collection

Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Respondents

IC 256785 under ICR 202211-0970-002 · OMB 0970-0564.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0564 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form M-11A-UF Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Respondents	Form and Instruction
Form M-11A-UF Program Director Questionnaire 3 - Program Director Questionnaire (Form M-11A-UF).docx	Form and Instruction
Form M-11C-UF Clinician Questionnaire 4 - Clinician Questionnaire (Form M-11C-UF).docx	Form and Instruction
Form M-11E-UF Case Manager Questionnaire 5 - Case Manager Questionnaire (Form M-11E-UF).docx	Form and Instruction
Form M-11G-UF Education Staff Questionnaire 6 - Education Staff Questionnaire (Form M-11G-UF).docx	Form and Instruction
Form M-11I-UF Medical Coordinator Questionnaire 7 - Medical Coordinator Questionnaire (Form M-11I-UF).docx	Form and Instruction
Form M-11J-UF Youth Care Worker Questionnaire 8 - Youth Care Worker Questionnaire (Form M-11J-UF).docx	Form and Instruction
Form M-11K-UF PSA Compliance Manager Questionnaire 9 - PSA Compliance Manager Questionnaire (Form M-11K-UF).docx	Form and Instruction

IC Title:

Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Respondents

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form M-11A-UF	Program Director Questionnaire	3 - Program Director Questionnaire (Form M-11A-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11C-UF	Clinician Questionnaire	4 - Clinician Questionnaire (Form M-11C-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11E-UF	Case Manager Questionnaire	5 - Case Manager Questionnaire (Form M-11E-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11G-UF	Education Staff Questionnaire	6 - Education Staff Questionnaire (Form M-11G-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11I-UF	Medical Coordinator Questionnaire	7 - Medical Coordinator Questionnaire (Form M-11I-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11J-UF	Youth Care Worker Questionnaire	8 - Youth Care Worker Questionnaire (Form M-11J-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11K-UF	PSA Compliance Manager Questionnaire	9 - PSA Compliance Manager Questionnaire (Form M-11K-UF).docx	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,792	1,792
Annual IC Time Burden (Hours)	1,792	1,792
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.