Information Collection

Care Coordinator Semi-Structured Interview (SSI)

IC 271503 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form B5 Care Coordinator Semi-Structured Interview (SSI) Form and Instruction
B5 Attachment B5 - Care Coordinator SSI PMHCA Attachment B5 - Care Coordinator SSI, V2, 2021-2023 PMHCA_NON-APPROVED_OMB.docx Form and Instruction
B5 Attachment B5 - Care Coordinator SSI PMHCA Attachment B5 - Care Coordinator SSI, V2, 2021-2023 PMHCA_NON-APPROVED_OMB.docx Form and Instruction
B13 Attachment B13 - Care Coordinator SSI MMHSUD Attachment B13 - Care Coordinator SSI, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx Form and Instruction
B13 Attachment B13 - Care Coordinator SSI MMHSUD Attachment B13 - Care Coordinator SSI, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Care Coordinator Semi-Structured Interview (SSI)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	B5	Attachment B5 - Care Coordinator SSI PMHCA	Attachment B5 - Care Coordinator SSI, V2, 2021-2023 PMHCA_NON-APPROVED_OMB.docx		Yes	Yes	Fillable Fileable
Form and Instruction	B13	Attachment B13 - Care Coordinator SSI MMHSUD	Attachment B13 - Care Coordinator SSI, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx		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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	67	67
Annual IC Time Burden (Hours)	50	50
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.