Assessment and Referral Tool

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

Documents and Forms

Document Name Document Type
Form Adult Assessment a Assessment and Referral Tool Form and Instruction
Adult Assessment a Adult Assessment and Referral Tool -Att-D-AdultAssessReferral-508-OMB2022_2022-01-11 _ clean.pdf Form and Instruction
Adult Assessment a Adult Assessment and Referral Tool -Att-D-AdultAssessReferral-508-OMB2022_2022-01-11 _ clean.pdf Form and Instruction
Child Assessment a Child Assessment and Referral Tool -Att-E-ChildAssessReferral-508-OMB2022_2022-01-11 _ clean.pdf Form and Instruction
Child Assessment a Child Assessment and Referral Tool -Att-E-ChildAssessReferral-508-OMB2022_2022-01-11 _ clean.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Assessment 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	-Att-D-AdultAssessReferral-508-OMB2022_2022-01-11 _ clean.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	Child Assessment and Referral Tool	Child Assessment and Referral Tool	-Att-E-ChildAssessReferral-508-OMB2022_2022-01-11 _ clean.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Assessment and Referral Tool	FR Citation: 75 FR 28264

Number of Respondents: 1,500	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	14,250	8,388	5,862
Annual IC Time Burden (Hours)	2,423	941	1,482
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.