Grantee Director - Web

Primary and Behavioral Health Care Integration Evaluation

Documents and Forms

Document Name Document Type
Form Director Survey Grantee Director - Web Form and Instruction
Director Survey Director Survey Attachment A PBHCI Director Survey_Updated 9.21.16.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Grantee Director - Web	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
Form and Instruction	Director Survey	Director Survey	Attachment A PBHCI Director Survey_Updated 9.21.16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 78	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	149	149
Annual IC Time Burden (Hours)	75	75
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.