Information Collection

Clinicians/Providers

IC 272542 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⚠️ Notice: This information collection may be referencing outdated material.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 Consumer Study Int Clinicians/Providers	Form and Instruction
Form Consumer Study Int Consumer Study Interest Form Clinicians/Providers	Form and Instruction
Consumer Study Int Consumer Study Interest Form Att K. Consumer Study Interest Form.docx	Form and Instruction
Consumer Study Int Consumer Study Interest Form Att K. Consumer Study Interest Form.docx	Form and Instruction

IC Title:

Clinicians/Providers

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	Consumer Study Interest Form				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: 180

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	1,440	1,440
Annual IC Time Burden (Hours)	360	360
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].