Information Collection

Program Implementation Survey

IC 271501 under ICR 202410-0906-001 · OMB 0906-0105.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0105 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form B3 Program Implementation Survey	Form and Instruction
Form B3 Attachment B3 - Program Implementation Survey PMHCA Program Implementation Survey	Form and Instruction
Form B11 Attachment B11 - Program Implementation Survey MMHSUD Program Implementation Survey	Form and Instruction
B3 Attachment B3 - Program Implementation Survey PMHCA Attachment B3 - Program Implementation Survey, V3, 2021-2023 PMHCA_NON-APPROVED_OMB.docx	Form and Instruction
B3 Attachment B3 - Program Implementation Survey PMHCA Attachment B3 - Program Implementation Survey, V3, 2021-2023 PMHCA_NON-APPROVED_OMB.docx	Form and Instruction
B11 Attachment B11 - Program Implementation Survey MMHSUD Attachment B11 - Program Implementation Survey, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx	Form and Instruction
B11 Attachment B11 - Program Implementation Survey MMHSUD Attachment B11 - Program Implementation Survey, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx	Form and Instruction

IC Title:

Program Implementation Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	B3				Yes	Yes	Fillable Fileable
Form and Instruction	B11				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 67

Number of Respondents for Small Entity: 67

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	67	67
Annual IC Time Burden (Hours)	22	22
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.

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