Information Collection

Practice-Level Survey

IC 271500 under ICR 202505-0906-005 · OMB 0906-0105.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1N Practice-Level Survey	Form and Instruction
Form 1N Attachment 1N - Practice Level Survey PMHCA Practice-Level Survey	Form and Instruction
Form 1F Attachment 1F - Practice Level Survey MMHSUD Practice-Level Survey	Form and Instruction
Form 1F 1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline Practice-Level Survey	Form and Instruction
Form 1N 1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redline Practice-Level Survey	Form and Instruction
1N Attachment 1N - Practice Level Survey PMHCA Attachment B2 - Practice Level Survey, V3, 2021-2023 PMHCA_NON-APPROVED_OMB.docx	Form and Instruction
1N Attachment 1N - Practice Level Survey PMHCA Attachment B2 - Practice Level Survey, V3, 2021-2023 PMHCA_NON-APPROVED_OMB.docx	Form and Instruction
1F Attachment 1F - Practice Level Survey MMHSUD Attachment B10 - Practice Level Survey, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx	Form and Instruction
1F Attachment 1F - Practice Level Survey MMHSUD Attachment B10 - Practice Level Survey, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx	Form and Instruction
1F 1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline 1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline.docx	Form and Instruction
1F 1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline 1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline.docx	Form and Instruction
1N 1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redli 1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redline.docx	Form and Instruction
1N 1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redli 1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redline.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Practice-Level Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1N	Yes	Yes	Fillable Fileable
Form and Instruction	1F	Yes	Yes	Fillable Fileable
Form and Instruction	1F	Yes	Yes	Fillable Fileable
Form and Instruction	1N	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,172

Number of Respondents for Small Entity: 6,172

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,172	6,172
Annual IC Time Burden (Hours)	2,037	2,037
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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