Agency Director/Administrator Interview

Mental Health Block Grant Ten Percent Set Aside Evaluation

Documents and Forms

Document Name Document Type
Form Agency Director/Ad Agency Director/Administrator Interview Form and Instruction
Agency Director/Ad Agency Director/Administrator Interview Attachment 2 - Agency Director_Administrator Interview 2-22-17.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Agency Director/Administrator Interview	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	Agency Director/Administrator Interview	Agency Director/Administrator Interview	Attachment 2 - Agency Director_Administrator Interview 2-22-17.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 64	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	64	64
Annual IC Time Burden (Hours)	128	128
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.