Information Collection

Champion and Community Resources SSI

IC 256680 under ICR 202302-0906-003 · OMB 0906-0074.

Documents and Forms

Documents and forms in this information collection
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

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	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 %

table that charts list of burden
	Approved	Previously Approved
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

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.