SAMHSA/CSAT's Viral Hepatitis Information Form

Enhancing Substance Abuse Treatment Services to Address Hepatitis Infection Among Intravenous Drug Users Hepatitis Testing and Vaccine Tracking Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0300 can be found here:

Documents and Forms

Document Name Document Type
Form Hepatitis Reportin SAMHSA/CSAT's Viral Hepatitis Information Form Form and Instruction
Hepatitis Reportin Hepatitis Reporting Form Hepatitis Reporting Form.doc Form and Instruction

Information Collection (IC) Details

IC Title:	SAMHSA/CSAT's Viral Hepatitis Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	Hepatitis Reporting Form	Hepatitis Reporting Form	Hepatitis Reporting Form.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	2,500	2,500
Annual IC Cost Burden (Dollars)	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.