CCBHC Survey

Evaluation of the Extension of the Certified Community Behavioral Health Clinic (CCBHC) Demonstration Program

Documents and Forms

Document Name Document Type
Attachment G. CCBHC Clinic Survey_instrument_Year One.docx Other-Survey Instrument Year One
Attachment G. CCBHC Clinic Survey_instrument_Year One.docx Other-Survey Instrument Year One
Attachment H. CCBHC Clinic Survey_instrument_Year Two.docx Other-Survey Instrument Year 2
Attachment H. CCBHC Clinic Survey_instrument_Year Two.docx Other-Survey Instrument Year 2

Information Collection (IC) Details

IC Title:	CCBHC Survey	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
Other-Survey Instrument Year One			Attachment G. CCBHC Clinic Survey_instrument_Year One.docx		No		Fillable Fileable
Other-Survey Instrument Year 2			Attachment H. CCBHC Clinic Survey_instrument_Year Two.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	150	150
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.