Program Implementation 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 1P Program Implementation Survey Form and Instruction
1P Attachment 1P - Program Implementation Survey PMHCA Attachment B3 - Program Implementation Survey, V3, 2021-2023 PMHCA_NON-APPROVED_OMB.docx Form and Instruction
1H Attachment 1H - Program Implementation Survey MMHSUD Attachment B11 - Program Implementation Survey, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx Form and Instruction
1H 1H_MCHB_0906-0105_MMHSUD Program Implementation Survey_R 1H_MCHB_0906-0105_MMHSUD Program Implementation Survey_Redline.docx Form and Instruction
1P 1P_MCHB_0906-0105_PMHCA Program Implementation Survey_Re 1P_MCHB_0906-0105_PMHCA Program Implementation Survey_Redline.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Program Implementation 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	1P	Attachment 1P - Program Implementation Survey PMHCA	Attachment B3 - Program Implementation Survey, V3, 2021-2023 PMHCA_NON-APPROVED_OMB.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1H	Attachment 1H - Program Implementation Survey MMHSUD	Attachment B11 - Program Implementation Survey, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1H	1H_MCHB_0906-0105_MMHSUD Program Implementation Survey_Redline	1H_MCHB_0906-0105_MMHSUD Program Implementation Survey_Redline.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1P	1P_MCHB_0906-0105_PMHCA Program Implementation Survey_Redline	1P_MCHB_0906-0105_PMHCA Program Implementation 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: 67	Number of Respondents for Small Entity: 67

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	67	67
Annual IC Time Burden (Hours)	22	22
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.