Information Collection

CCBHC - Evaluation Clinic Survey

IC 271656 under ICR 202505-0990-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment E. CCBHC Demo Eval Clinic Survey_OMB.docx	Other-Survey
Attachment E. CCBHC Demo Eval Clinic Survey_OMB.docx	Other-Survey
Attachment E. CCBHC Demo Eval Clinic Survey_OMB.docx Attachment E - Client Survey	IC Document
Attachment E. CCBHC Demo Eval Clinic Survey_OMB.docx Attachment E - Client Survey	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 231

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	231	231
Annual IC Time Burden (Hours)	924	924
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment E - Client Survey		10/16/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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