Information Collection

Practice-Level Survey

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

Documents and Forms

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1N	Attachment 1N - Practice Level Survey PMHCA	Attachment B2 - Practice Level Survey, V3, 2021-2023 PMHCA_NON-APPROVED_OMB.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1F	Attachment 1F - Practice Level Survey MMHSUD	Attachment B10 - Practice Level Survey, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1F	1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline	1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1N	1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redline	1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redline.docx	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 %

	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

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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