OMB control number
Mental Health Block Grant Ten Percent Set Aside Evaluation
OMB 0930-0376 · HHS/SAMHSA.
OMB 0930-0376
The purpose of this 3-year evaluation is to assess the relationship between fidelity of selected coordinated specialty care (CSC) programs supported with Mental Health Block Grant (MHBG) Ten Percent Set Aside funding and participant outcomes. There are approximately 250 sites implementing CSC programs with MHBG ten percent set aside funding. All 250 sites will be asked to report on their implementation through an online survey. Up to 32 CSC sites across the nation will be recruited to participate in a process and outcome evaluation.
The latest form for Mental Health Block Grant Ten Percent Set Aside Evaluation expires 2020-08-31 and is listed under ICR 201706-0930-001.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form Possible Admin. Da Possible Admin. Data Elements | Form and Instruction |
| Form Fidelity Interview Fidelity Interview | Form and Instruction |
| Form State MH Authority State MH Authority Interview | Form and Instruction |
| Form CSC Participant In CSC Participant Interview | Form and Instruction |
| Form CSC Staff Intervie CSC Staff Interview | Form and Instruction |
| Form Agency Director/Ad Agency Director/Administrator Interview | Form and Instruction |
| Form Site Survey Site Survey | Form and Instruction |
| OMB_Supporting_Statement_A 6-19-17.docx | Supporting Statement A |
| OMB_Supporting_Statement_B 6-15-17.docx | Supporting Statement B |
 Possible Admin. Data Elements |
Form and Instruction |
| Fidelity Interview |
Form and Instruction |
| State MH Authority Interview |
Form and Instruction |
| CSC Participant Interview |
Form and Instruction |
| CSC Staff Interview |
Form and Instruction |
| Agency Director/Administrator Interview |
Form and Instruction |
| Site Survey |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 201706-0930-001 | New collection (Request for a new OMB Control Number) | 2017-06-21 | Approved without change |
OMB Details
Site Survey
Federal Enterprise Architecture: Health - Public Health Monitoring
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form Site Survey | Site Survey | Fillable Fileable | Form and instruction |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.