Evaluating the Applicability and Use of The Commmunity Guide among SAMHSA Grantees

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Documents and Forms

Document Name Document Type
Evaluating the Applicability and Use of The Commmunity Guide among SAMHSA Grantees Form
SAMHSA Grantees Survey SAMHSA Grantees survey 1-23-2017.pdf Form
Provide Feedback on The Community Guide invitation email script (SAMHSA) 1-13-17.docx Email Invitation IC Document
Provide Feedback on The Community Guide follow-up email script (SAMHSA) 1-13-17.docx Follow-up Email IC Document
Screenshot of Survey page 1a.PNG Survey page 1a IC Document
Screenshot of SAMHSA Survey page 1b.PNG Survey page 1b IC Document
Screenshot of SAMHSA Survey page 2.PNG Survey page 2 IC Document
Screenshot of SAMHSA Survey page 3.PNG Survey page 3 IC Document
Screenshot of SAMHSA Survey page 4.PNG Survey page 4 IC Document
Screenshot of SAMHSA Survey page 5.PNG Survey page 5 IC Document
Screenshot of SAMHSA Survey page 6.PNG Survey page 6 IC Document
Screenshot of SAMHSA Survey page 7.PNG Survey page 7 IC Document
Screenshot of SAMHSA Survey page 8.PNG Survey page 8 IC Document
Screenshot of SAMHSA Survey page 9.PNG Survey page 9 IC Document
Screenshot of SAMHSA Survey page 10.PNG Survey page 10 IC Document
Screenshot of SAMHSA Survey page 11.PNG Survey page 11 IC Document
Screenshot of SAMHSA Survey page 12.PNG Survey page 12 IC Document
Screenshot of SAMHSA Survey page 13.PNG Survey page 13 IC Document
Fast_Track_GenIC_Request CGB Customer feedback SAMHSA grantees 1-26-17.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Evaluating the Applicability and Use of The Commmunity Guide among SAMHSA Grantees	Agency IC Tracking Number:	17NQ

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	none	SAMHSA Grantees Survey	SAMHSA Grantees survey 1-23-2017.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 255	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
Annual Number of Responses for this IC	255	255
Annual IC Time Burden (Hours)	64	64
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Email Invitation	Provide Feedback on The Community Guide invitation email script (SAMHSA) 1-13-17.docx	01/25/2017
Follow-up Email	Provide Feedback on The Community Guide follow-up email script (SAMHSA) 1-13-17.docx	01/25/2017
Survey page 1a	Screenshot of Survey page 1a.PNG	01/25/2017
Survey page 1b	Screenshot of SAMHSA Survey page 1b.PNG	01/25/2017
Survey page 2	Screenshot of SAMHSA Survey page 2.PNG	01/25/2017
Survey page 3	Screenshot of SAMHSA Survey page 3.PNG	01/25/2017
Survey page 4	Screenshot of SAMHSA Survey page 4.PNG	01/25/2017
Survey page 5	Screenshot of SAMHSA Survey page 5.PNG	01/25/2017
Survey page 6	Screenshot of SAMHSA Survey page 6.PNG	01/25/2017
Survey page 7	Screenshot of SAMHSA Survey page 7.PNG	01/25/2017
Survey page 8	Screenshot of SAMHSA Survey page 8.PNG	01/25/2017
Survey page 9	Screenshot of SAMHSA Survey page 9.PNG	01/25/2017
Survey page 10	Screenshot of SAMHSA Survey page 10.PNG	01/25/2017
Survey page 11	Screenshot of SAMHSA Survey page 11.PNG	01/25/2017
Survey page 12	Screenshot of SAMHSA Survey page 12.PNG	01/25/2017
Survey page 13	Screenshot of SAMHSA Survey page 13.PNG	01/25/2017
Request for Approval	Fast_Track_GenIC_Request CGB Customer feedback SAMHSA grantees 1-26-17.docx	01/31/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.