Information Collection

ACF Behavioral Health Survey

IC 258666 under ICR 202411-0970-002 · OMB 0970-0531.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0531 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Behavioral Health Survey - English - 1.23.23.docx	Other-Survey
Behavioral Health Survey - English - 1.23.23.docx	Other-Survey
SSA Template - Formative for ACF Program Support - BH survey - clean final draft 1.19.23.docx Supporting Statement A	IC Document
SSA Template - Formative for ACF Program Support - BH survey - clean final draft 1.19.23.docx Supporting Statement A	IC Document
SSB Template - Formative for ACF Program Support- BH survey - clean final draft 1.19.23.docx Supporting Statement B	IC Document
SSB Template - Formative for ACF Program Support- BH survey - clean final draft 1.19.23.docx Supporting Statement B	IC Document
Behavioral Health Survey - Spanish - 1.24.23.docx Survey Spanish Version	IC Document
Behavioral Health Survey - Spanish - 1.24.23.docx Survey Spanish Version	IC Document

IC Title:

ACF Behavioral Health Survey

Agency IC Tracking Number:

IC Status: Unchanged

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
Other-Survey			Behavioral Health Survey - English - 1.23.23.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	73	73
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	SSA Template - Formative for ACF Program Support - BH survey - clean final draft 1.19.23.docx	02/22/2023
Supporting Statement B	SSB Template - Formative for ACF Program Support- BH survey - clean final draft 1.19.23.docx	02/22/2023
Survey Spanish Version	Behavioral Health Survey - Spanish - 1.24.23.docx	02/22/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.