Information Collection

Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures

IC 219429 under ICR 202603-0906-002 · OMB 0906-0017.

Documents and Forms

Document Name Document Type
Form 1 Demographic, Service Utilization, Select Clinical Indicators, and Program Locations Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures Form and Instruction
Form 1 Demographic, Service Utilization, Select Clinical Indicators, and Program Locations Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures Form and Instruction
Form 2 Performance Indicators and Systems Outcome Measures Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures Form and Instruction
Form 2 Performance Indicators and Systems Outcome Measures Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures Form and Instruction
1 Demographic, Service Utilization, Select Clinical Indica Attachment A_Form 1 Revised.docx Form and Instruction
1 Demographic, Service Utilization, Select Clinical Indica Attachment A_0906-0017_Form 1_Revised 04162026.docx Form and Instruction
2 Performance Indicators and Systems Outcome Measures Attachment B_Form 2 Revised.docx Form and Instruction
2 Performance Indicators and Systems Outcome Measures Attachment B_0906-0017_Form 2 Revised 04162026.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Demographic, Service Utilization, Select Clinical Indicators, and Program Locations	Attachment A_0906-0017_Form 1_Revised 04162026.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	Performance Indicators and Systems Outcome Measures	Attachment B_0906-0017_Form 2 Revised 04162026.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	65,576	21,840	43,736
Annual IC Cost Burden (Dollars)	0	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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