Information Collection

Block Grant Application

IC 7545 under ICR 202304-0930-002 · OMB 0930-0168.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0168 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SAMHSA_BG_Applicat Block Grant Application	Form and Instruction
SAMHSA_BG_Applicat SAMHSA_BG_Application_2024-25 SAMHSA_BG_Application_2024-25_clean_4.7.2023.docx	Form and Instruction
SAMHSA_BG_Applicat SAMHSA_BG_Application_2024-25 SAMHSA_BG_Application_2024-25_clean_4.7.2023.docx	Form and Instruction
2024 to 2025 SABG Report Final 3.26.23 v3 OMB Clean.docx 2024 to 2025 SABG Report	IC Document
2024 to 2025 SABG Report Final 3.26.23 v3 OMB Clean.docx 2024 to 2025 SABG Report	IC Document
SAMHSA_BG_Application_2024-25_clean_4.7.2023.docx 2024-2025 MHBG Report	IC Document
SAMHSA_BG_Application_2024-25_clean_4.7.2023.docx 2024-2025 MHBG Report	IC Document

IC Title:

Block Grant Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	SAMHSA_BG_Application_2024-25	SAMHSA_BG_Application_2024-25	SAMHSA_BG_Application_2024-25_clean_4.7.2023.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 119

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	119	0	119
Annual IC Time Burden (Hours)	24,613	-8,880	33,493
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2024 to 2025 SABG Report	2024 to 2025 SABG Report Final 3.26.23 v3 OMB Clean.docx	05/02/2023
2024-2025 MHBG Report	SAMHSA_BG_Application_2024-25_clean_4.7.2023.docx	05/02/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.