Information Collection

Interview

IC 195358 under ICR 202408-0930-003 · OMB 0930-0110.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0110 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form In-Person CAI Ques Interview	Form and Instruction
In-Person CAI Ques In-Person CAI Questionnaire Attachment N_In-Person CAI Questionnaire_v2.pdf	Form and Instruction
In-Person CAI Ques In-Person CAI Questionnaire Attachment N_In-Person CAI Questionnaire_Final 9-30-24.pdf	Form and Instruction
Web-based CAI Ques Web-based CAI Questionnaire Attachment WEB-4_Web-based CAI Questionnaire.pdf	Form and Instruction
Web-based CAI Ques Web-based CAI Questionnaire Attachment WEB-4_Web-based CAI Questionnaire_Final 9-30-24.pdf	Form and Instruction
In-Person CAI Ques In-Person CAI Questionnaire 2025 In-Person IVW English_11725.docx	Form and Instruction
Web-based CAI Ques Web-based CAI Questionnaire 2025 Web IVW English_11725.docx	Form and Instruction

IC Title:

Interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	In-Person CAI Questionnaire	In-Person CAI Questionnaire	2025 In-Person IVW English_11725.docx		Yes	Yes	Fillable Fileable
Form and Instruction	Web-based CAI Questionnaire	Web-based CAI Questionnaire	2025 Web IVW English_11725.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Alcohol, Drug Abuse, and Mental Health Epidemiologic Data (HHS/SAMHSA/OA)

FR Citation: 84 FR 27341

Number of Respondents: 67,507

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	67,507	0	67,507
Annual IC Time Burden (Hours)	68,047	540	67,507
Annual IC Cost Burden (Dollars)	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.