State and Territory Survey

State Minority Health Entity Survey

Documents and Forms

Document Name Document Type
0990-OMH Attachment B - Interview Topics and Data Collection Tables Handout 7-31-15 final.docx Other-survey
0990-Attachment A - OMH State and Territorial Survey final Edits.61915.docx Other-survey
0990 OMH Attachment C - Technical Expert Panel Membership Roster.JNG Edits 6915.docx Attachment C IC Document
0990-OMH_Attachment D - Introductory Letters.61915 final.docx Introductory letter IC Document

Information Collection (IC) Details

IC Title:	State and Territory Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-survey			0990-OMH Attachment B - Interview Topics and Data Collection Tables Handout 7-31-15 final.docx		No		Fillable Printable
Other-survey			0990-Attachment A - OMH State and Territorial Survey final Edits.61915.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	54	54
Annual IC Time Burden (Hours)	81	81
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment C	0990 OMH Attachment C - Technical Expert Panel Membership Roster.JNG Edits 6915.docx	10/20/2015
Introductory letter	0990-OMH_Attachment D - Introductory Letters.61915 final.docx	10/20/2015

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