Practice-Level Survey

Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access and Screening and Treatment for Maternal Mental Health and Substance Use Disorders Programs Project

Documents and Forms

Document Name Document Type
Form 1N Practice-Level Survey Form and Instruction
1N Attachment 1N - Practice Level Survey PMHCA Attachment B2 - Practice Level Survey, V3, 2021-2023 PMHCA_NON-APPROVED_OMB.docx Form and Instruction
1F Attachment 1F - Practice Level Survey MMHSUD Attachment B10 - Practice Level Survey, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx Form and Instruction
1F 1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline 1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline.docx Form and Instruction
1N 1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redli 1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redline.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Practice-Level Survey	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1N	Attachment 1N - Practice Level Survey PMHCA	Attachment B2 - Practice Level Survey, V3, 2021-2023 PMHCA_NON-APPROVED_OMB.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1F	Attachment 1F - Practice Level Survey MMHSUD	Attachment B10 - Practice Level Survey, V2, 2023 MMHSUD_NON-APPROVED_OMB.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1F	1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline	1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1N	1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redline	1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redline.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,172	Number of Respondents for Small Entity: 6,172

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	6,172	6,172
Annual IC Time Burden (Hours)	2,037	2,037
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.