Provider Group-Behavioral Health Preventive Care

Behavioral Health Preventive Care Assissment Focus Group

Documents and Forms

Document Name Document Type
Form no form number Provider Group-Behavioral Health Preventive Care Form and Instruction
no form number Provider Questions Provider Questions (final) 10-10-08.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Provider Group-Behavioral Health Preventive Care	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.5

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	no form number	Provider Questions	Provider Questions (final) 10-10-08.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	60	60
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.