Grantee - Quarterly Reports

Primary and Behavioral Health Care Integration Program

Documents and Forms

Document Name Document Type
Form Quarterly Report Grantee - Quarterly Reports Form and Instruction
Quarterly Report Quarterly Report Attachment 1 Quarterly Report.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Grantee - Quarterly Reports	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	Quarterly Report	Quarterly Report	Attachment 1 Quarterly Report.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 172	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	688	408	280
Annual IC Time Burden (Hours)	1,376	816	560
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.