Health Professional Survey

Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access and Screening and Treatment for Maternal Mental Health and Substance Use Disorders Programs Project

Documents and Forms

Document Name Document Type
Form 1M Health Professional Survey Form and Instruction
1M Attachment 1M - Health Professional Survey PMHCA Attachment B1 - Health Professional Survey V3 2021-2023 PMHCA_NON-APPROVED_Clean_9-16-24.docx Form and Instruction
1E Attachment 1E - Health Professional Survey MMHSUD Attachment B9 - Health Professional Survey V2 2023 MMHSUD_NON-APPROVED_Clean_9-16-24.docx Form and Instruction
1E 1E_MCHB_0906-0105_MMHSUD Health Professional Survey_Redl 1E_MCHB_0906-0105_MMHSUD Health Professional Survey_Redline.docx Form and Instruction
1M 1M_MCHB_0906-0105_MCHB_PMHCA Health Professional Survey_ 1M_MCHB_0906-0105_MCHB_PMHCA Health Professional Survey_Redline.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Health Professional Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1M	Attachment 1M - Health Professional Survey PMHCA	Attachment B1 - Health Professional Survey V3 2021-2023 PMHCA_NON-APPROVED_Clean_9-16-24.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1E	Attachment 1E - Health Professional Survey MMHSUD	Attachment B9 - Health Professional Survey V2 2023 MMHSUD_NON-APPROVED_Clean_9-16-24.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1E	1E_MCHB_0906-0105_MMHSUD Health Professional Survey_Redline	1E_MCHB_0906-0105_MMHSUD Health Professional Survey_Redline.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1M	1M_MCHB_0906-0105_MCHB_PMHCA Health Professional Survey_Redline	1M_MCHB_0906-0105_MCHB_PMHCA Health Professional Survey_Redline.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23,256	Number of Respondents for Small Entity: 23,256

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	23,256	23,256
Annual IC Time Burden (Hours)	7,674	7,674
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.