Service Provider Feedback Form

Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)

Documents and Forms

Document Name Document Type
Form Service Provider F Service Provider Feedback Form Form and Instruction
Service Provider F Service Provider Feedback Form -Att-G-ServiceProviderFeedback-508-OMB2022_2021-11-03 _ clean.pdf Form and Instruction
Service Provider F Service Provider Feedback Form -Att-G-ServiceProviderFeedback-508-OMB2022_2021-11-03 _ clean.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Service Provider Feedback Form	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	Service Provider Feedback Form	Service Provider Feedback Form	-Att-G-ServiceProviderFeedback-508-OMB2022_2021-11-03 _ clean.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Service Provider Feedback Form	FR Citation: 75 FR 28264

Number of Respondents: 750	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	750	650	100
Annual IC Time Burden (Hours)	308	267	41
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.