Information Collection

Behavioral Health Consultation Provider Semi-Structured Interview (SSI)

IC 271502 under ICR 202505-0906-005 · OMB 0906-0105.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1I Behavioral Health Consultation Provider Semi-Structured Interview (SSI)	Form and Instruction
Form 1I Attachment 1I - Behavioral Health Consultation Provider SSI PMHCA Behavioral Health Consultation Provider Semi-Structured Interview (SSI)	Form and Instruction
Form 1A Attachment 1A - Behavioral Health Consultation Provider SSI MMHSUD Behavioral Health Consultation Provider Semi-Structured Interview (SSI)	Form and Instruction
Form 1A 1A_MCHB_0906-0105_MMHSUD BH Consultation Provider SSI_Redline Behavioral Health Consultation Provider Semi-Structured Interview (SSI)	Form and Instruction
Form 1I 1I_MCHB_0906-0105_PMHCA BH Consultation Provider SSI_Redline Behavioral Health Consultation Provider Semi-Structured Interview (SSI)	Form and Instruction
1I Attachment 1I - Behavioral Health Consultation Provider Attachment B8 - Behavioral Health Consultation Provider SSI, V1, 2021-2023 PMHCA_NON-APPROVED_OMB.docx	Form and Instruction
1I Attachment 1I - Behavioral Health Consultation Provider Attachment B8 - Behavioral Health Consultation Provider SSI, V1, 2021-2023 PMHCA_NON-APPROVED_OMB.docx	Form and Instruction
1A Attachment 1A - Behavioral Health Consultation Provider Attachment B16 - Behavioral Health Consultation Provider SSI, V1, 2023 MMHSUD_NON-APPROVED_OMB.docx	Form and Instruction
1A Attachment 1A - Behavioral Health Consultation Provider Attachment B16 - Behavioral Health Consultation Provider SSI, V1, 2023 MMHSUD_NON-APPROVED_OMB.docx	Form and Instruction
1A 1A_MCHB_0906-0105_MMHSUD BH Consultation Provider SSI_Re 1A_MCHB_0906-0105_MMHSUD BH Consultation Provider SSI_Redline.docx	Form and Instruction
1A 1A_MCHB_0906-0105_MMHSUD BH Consultation Provider SSI_Re 1A_MCHB_0906-0105_MMHSUD BH Consultation Provider SSI_Redline.docx	Form and Instruction
1I 1I_MCHB_0906-0105_PMHCA BH Consultation Provider SSI_Red 1I_MCHB_0906-0105_PMHCA BH Consultation Provider SSI_Redline.docx	Form and Instruction
1I 1I_MCHB_0906-0105_PMHCA BH Consultation Provider SSI_Red 1I_MCHB_0906-0105_PMHCA BH Consultation Provider SSI_Redline.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Behavioral Health Consultation Provider Semi-Structured Interview (SSI)

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	1I	Yes	Yes	Fillable Fileable
Form and Instruction	1A	Yes	Yes	Fillable Fileable
Form and Instruction	1A	Yes	Yes	Fillable Fileable
Form and Instruction	1I	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: 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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	67	67
Annual IC Time Burden (Hours)	50	50
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].