Asessment and Referral Tool

Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0270 can be found here:

Documents and Forms

Document Name Document Type
Form Adult_Assessment_a Asessment and Referral Tool Form and Instruction
Adult_Assessment_a Adult_Assessment_and_Referral_Tool 3_20_15_Attachment D_Adult_Assessment_and_Referral_Tool.docx Form and Instruction
Child_Youth_Assess Child_Youth_Assessment_and_Referral 3_20_15_Attachment E_Child_Youth_Assessment_and_Referral_Tool.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Asessment and Referral Tool	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	Adult_Assessment_and_Referral_Tool	Adult_Assessment_and_Referral_Tool	3_20_15_Attachment D_Adult_Assessment_and_Referral_Tool.docx		Yes	Yes	Fillable Fileable
Form and Instruction	Child_Youth_Assessment_and_Referral	Child_Youth_Assessment_and_Referral	3_20_15_Attachment E_Child_Youth_Assessment_and_Referral_Tool.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,800	2,800
Annual IC Time Burden (Hours)	700	700
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.