Information Collection

Grantee/Healthcare Organization Administrator

IC 272540 under ICR 202411-0930-003 · OMB 0930-0401.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0401 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Behavioral Health Grantee/Healthcare Organization Administrator	Form and Instruction
Form Behavioral Health Behavioral Health Provider Survey Grantee/Healthcare Organization Administrator	Form and Instruction
Form Key Informant Inte Key Informant Interview Case Study Grantee/Healthcare Organization Administrator	Form and Instruction
Form Key Informant Inte Key Informant Interview Cost Study Grantee/Healthcare Organization Administrator	Form and Instruction
Behavioral Health Behavioral Health Provider Survey Att C. Behavioral Health Provider Survey_OMB_clean.docx	Form and Instruction
Behavioral Health Behavioral Health Provider Survey Att C. Behavioral Health Provider Survey_OMB_clean.docx	Form and Instruction
Key Informant Inte Key Informant Interview Case Study Att D. Key Informant Interview Guide_OMB_clean.docx	Form and Instruction
Key Informant Inte Key Informant Interview Case Study Att D. Key Informant Interview Guide_OMB_clean.docx	Form and Instruction
Key Informant Inte Key Informant Interview Cost Study Att E_A. Key Informant Interview Guide-Cost_Sub_Study_OMB_clean.docx	Form and Instruction
Key Informant Inte Key Informant Interview Cost Study Att E_A. Key Informant Interview Guide-Cost_Sub_Study_OMB_clean.docx	Form and Instruction

IC Title:

Grantee/Healthcare Organization Administrator

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Behavioral Health Provider Survey	Yes	Yes	Fillable Fileable
Form and Instruction	Key Informant Interview Case Study	Yes	Yes	Fillable Fileable
Form and Instruction	Key Informant Interview Cost Study	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: GLS National Outcomes Evaluation Suicide Prevention Data Center

FR Citation: 75 FR 28264

Number of Respondents: 56

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
Annual Number of Responses for this IC	168	168
Annual IC Time Burden (Hours)	99	99
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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