Information Collection

Consumer/Grantee/Clinic Interviews

IC 273027 under ICR 202412-0930-003 · OMB 0930-0402.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0402 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Consumer Family Me Consumer/Grantee/Clinic Interviews	Form and Instruction
Consumer Family Me Consumer Family Member Organization Interview Attachment D Consumer and Family Member Organization Interview Protocol.docx	Form and Instruction
Grantee Project Di Grantee Project Director Interview Protocol Attachment E Grantee Project Director Interview Protocol.docx	Form and Instruction
Clinic Leadership Clinic Leadership Interview Protocol Attachment F Clinic Leadership Interview Protocol.docx	Form and Instruction
Clinic Leadership Clinic Leadership Interview Protocol Attachment F Clinic Leadership Interview Protocol.docx	Form and Instruction
Clinic Staff Inter Clinic Staff Interview Protocol Attachment G Clinic Staff Interview Protocol.docx	Form and Instruction
Clinic Staff Inter Clinic Staff Interview Protocol Attachment G Clinic Staff Interview Protocol.docx	Form and Instruction
Clinic Partner Org Clinic Partner Organization Interview Protocol Attachment H Clinic Partner Organization Interview Protocol.docx	Form and Instruction
Clinic Partner Org Clinic Partner Organization Interview Protocol Attachment H Clinic Partner Organization Interview Protocol.docx	Form and Instruction
Grantee Interview Grantee Interview Guide Attachment E Grantee Project Director Interview Protocol CLEAN.docx	Form and Instruction
Consumer and Famil Consumer and Family Member Interview Guide Attachment D Consumer and Family Member Organization Interview Protocol CLEAN.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Consumer/Grantee/Clinic Interviews

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Clinic Leadership Interview Protocol	Clinic Leadership Interview Protocol	Attachment F Clinic Leadership Interview Protocol.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Clinic Staff Interview Protocol	Clinic Staff Interview Protocol	Attachment G Clinic Staff Interview Protocol.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Clinic Partner Organization Interview Protocol	Clinic Partner Organization Interview Protocol	Attachment H Clinic Partner Organization Interview Protocol.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Grantee Interview Guide	Grantee Interview Guide	Attachment E Grantee Project Director Interview Protocol CLEAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Consumer and Family Member Interview Guide	Consumer and Family Member Interview Guide	Attachment D Consumer and Family Member Organization Interview Protocol CLEAN.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: CCBHC-E

FR Citation: 75 FR 28264

Number of Respondents: 720

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	720	720
Annual IC Time Burden (Hours)	720	720
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.