PMHCA Practice Level Survey

Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access Program and the Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program

Documents and Forms

Document Name Document Type
Form 2 PMHCA Practice Level Survey Form and Instruction
Form 2 PMHCA Practice Level Survey Form and Instruction
2 Practice Level Survey Attachment B2 - Practice-Level Survey2 - Copy.docx Form and Instruction
2 Practice Level Survey Attachment B2 - Practice-Level Survey2 - Copy.docx Form and Instruction

Information Collection (IC) Details

IC Title:	PMHCA Practice Level Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Practice Level Survey	Attachment B2 - Practice-Level Survey2 - 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: 2,950	Number of Respondents for Small Entity: 2,950

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,950	2,950
Annual IC Time Burden (Hours)	2,213	2,213
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.