OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

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

IC 256786 under ICR 202211-0970-002 · OMB 0970-0564.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form Form M-11A-UF
Program Director Questionnaire Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping		 Form and Instruction
Form Form M-11C-UF
Clinician Questionnaire Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping		 Form and Instruction
Form Form M-11E-UF
Case Manager Questionnaire Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping		 Form and Instruction
Form Form M-11G-UF
Education Staff Questionnaire Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping		 Form and Instruction
Form Form M-11I-UF
Medical Coordinator Questionnaire Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping		 Form and Instruction
Form Form M-11J-UF
Youth Care Worker Questionnaire Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping		 Form and Instruction
Form Form M-11K-UF
PSA Compliance Manager Questionnaire Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping		 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

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 Form M-11A-UF Yes Yes Fillable Fileable
Form and Instruction Form M-11C-UF Yes Yes Fillable Fileable
Form and Instruction Form M-11E-UF Yes Yes Fillable Fileable
Form and Instruction Form M-11G-UF Yes Yes Fillable Fileable
Form and Instruction Form M-11I-UF Yes Yes Fillable Fileable
Form and Instruction Form M-11J-UF Yes Yes Fillable Fileable
Form and Instruction Form M-11K-UF Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,800 0 1,800 0 0 0
Annual IC Time Burden (Hours) 1,800 0 1,800 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 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.
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