OMB
.report
Search
BHIT Survey
Behavioral Health Information Technologies Survey
OMB: 0930-0352
IC ID: 216733
OMB.report
HHS/SAMHSA
OMB 0930-0352
ICR 201505-0930-001
IC 216733
( )
Documents and Forms
Document Name
Document Type
Form BHITS
BHIT Survey
Form and Instruction
BHITS BHITS
Attachment 1_Survey Questions_05_28_15.docx
Form and Instruction
Attachment 2_Data Dictionary-Key-Terms-Definitions_2_27_15.docx
Data Dictionary
IC Document
Attachment 3_Survey Question Crosswalk to Research Question and Domain_052215.docx
Survey Question Crosswalk
IC Document
Attachment 4_Pilot_Protocol_Schedule_Documents-2_27_15.docx
Pilot_Protocol
IC Document
Attachment 5_GranteeLetter_2_27_15.doc
Grantee Letter
IC Document
Attachment 6_ScrennShots._5_27_15pdf
Screnn Shots
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
BHIT Survey
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
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
BHITS
BHITS
Attachment 1_Survey Questions_05_28_15.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
374
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 New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
374
0
374
0
0
0
Annual IC Time Burden (Hours)
150
0
150
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Data Dictionary
Attachment 2_Data Dictionary-Key-Terms-Definitions_2_27_15.docx
05/28/2015
Survey Question Crosswalk
Attachment 3_Survey Question Crosswalk to Research Question and Domain_052215.docx
05/28/2015
Pilot_Protocol
Attachment 4_Pilot_Protocol_Schedule_Documents-2_27_15.docx
05/28/2015
Grantee Letter
Attachment 5_GranteeLetter_2_27_15.doc
05/28/2015
Screnn Shots
Attachment 6_ScrennShots._5_27_15pdf
05/28/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.