State Medicaid official-telephone interview

Evaluation of the Certified Community Behavioral Health Clinic Demonstration

Documents and Forms

Document Name Document Type
Attachment E CCBHC Evaluation Baseline State Medicaid Official Interview_OMB.docx Other-evaluation
Attachment G CCBHC Evaluation Midpoint State Medicaid Official Interview.docx Other-interview
Attachment I CCBHC Evaluation End State Medicaid Official Interview.docx Other-interview

Information Collection (IC) Details

IC Title:	State Medicaid official-telephone interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-evaluation	Attachment E CCBHC Evaluation Baseline State Medicaid Official Interview_OMB.docx	No	Paper Only
Other-interview	Attachment G CCBHC Evaluation Midpoint State Medicaid Official Interview.docx	No	Paper Only
Other-interview	Attachment I CCBHC Evaluation End State Medicaid Official Interview.docx	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8	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	48	48
Annual IC Time Burden (Hours)	48	48
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.