SAMHSA Checklist for SF-5161

Documents and Forms

Document Name Document Type
Form Checklist SF-5161 SAMHSA Checklist for SF-5161 Form and Instruction
Checklist SF-5161 Checklist SF-5161 Attachment A SF_5161-Chcklist_2.7.17.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SAMHSA Checklist for SF-5161	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	Checklist SF-5161	Checklist SF-5161	Attachment A SF_5161-Chcklist_2.7.17.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,669	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	Previously Approved
Annual Number of Responses for this IC	2,669	-4,788	7,457
Annual IC Time Burden (Hours)	801	-19,129	19,930
Annual IC Cost Burden (Dollars)	0	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.