Provider Survey

National Evaluation of SAMHSA's Youth Programs

Documents and Forms

Document Name Document Type
Form Provider Survey Provider Survey Form and Instruction
Provider Survey Provider Survey Attachment 5 Provider Survey.docx Form and Instruction
Attachment 1 Evaluation Questions.docx Evaluation Questions IC Document
Attachment 7 Interview Guides Supporting Documents.docx Interview Guide Supporting Documents IC Document
Attachment 8 Provider Survey Supporting Documents.doc Provider Survey Supporting Documents IC Document
Attachment 9 Provider Survey table shells.docx Provider Survey Table Shells IC Document

Information Collection (IC) Details

IC Title:	Provider 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
Form and Instruction	Provider Survey	Provider Survey	Attachment 5 Provider Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 74	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	74	74
Annual IC Time Burden (Hours)	74	74
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Evaluation Questions	Attachment 1 Evaluation Questions.docx	06/23/2016
Interview Guide Supporting Documents	Attachment 7 Interview Guides Supporting Documents.docx	06/23/2016
Provider Survey Supporting Documents	Attachment 8 Provider Survey Supporting Documents.doc	06/23/2016
Provider Survey Table Shells	Attachment 9 Provider Survey table shells.docx	06/23/2016

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