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

Documents and Forms

Document Name Document Type
Form Hepatitis Reportin SAMHSA/CSAT's Viral Hepatitis Information Form Form
0300-Public Burden Statement.doc Instruction
Hepatitis Reportin Hepatitis Reporting Form Attachment A. 3-14-13.docx Form
Attachment B. 3-14-13.docx Project Management IT/Database Design Plan IC Document

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	Hepatitis Reporting Form	Hepatitis Reporting Form	Attachment A. 3-14-13.docx		Yes	Yes	Fillable Printable
Instruction			0300-Public Burden Statement.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800	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
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Project Management IT/Database Design Plan	Attachment B. 3-14-13.docx	03/19/2013

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