DBHNAS (State/Territory)

Disaster Technical Assistance Center Disaster Mental Health Needs Assessment and Customer Satisfaction Survey

Documents and Forms

Document Name Document Type
Form State-Territory DBHNAS (State/Territory) Form and Instruction
State-Territory State-Territory Attachment A1 State-Territory NAS.docx Form and Instruction

Information Collection (IC) Details

IC Title:	DBHNAS (State/Territory)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	State-Territory	State-Territory	Attachment A1 State-Territory NAS.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 77	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-77	77
Annual IC Time Burden (Hours)	-39	39
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.