Information Collection

CCBHC Interview Protocol

IC 271658 under ICR 202505-0990-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment B. CCBHC Demo Eval Clinic Interview Protocol_OMB.docx	Instruction
Attachment B. CCBHC Demo Eval Clinic Interview Protocol_OMB.docx	Instruction
Attachment B. CCBHC Demo Eval Clinic Interview Protocol_OMB.docx Attachment B - CCBHC Clinic Interview	IC Document
Attachment B. CCBHC Demo Eval Clinic Interview Protocol_OMB.docx Attachment B - CCBHC Clinic Interview	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
Instruction					Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B - CCBHC Clinic Interview		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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