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Grantee/Healthcare Organization Administrator
Zero Suicide Evaluation
OMB:
IC ID: 272540
OMB.report
SAMHSA
ICR 202411-0930-003
IC 272540
( )
Documents and Forms
Document Name
Document Type
Form Behavioral Health
Grantee/Healthcare Organization Administrator
Form and Instruction
Behavioral Health Behavioral Health Provider Survey
Att C. Behavioral Health Provider Survey_OMB_clean.docx
Form and Instruction
Key Informant Inte Key Informant Interview Case Study
Att D. Key Informant Interview Guide_OMB_clean.docx
Form and Instruction
Key Informant Inte Key Informant Interview Cost Study
Att E_A. Key Informant Interview Guide-Cost_Sub_Study_OMB_clean.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Grantee/Healthcare Organization Administrator
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
Behavioral Health Provider Survey
Behavioral Health Provider Survey
Att C. Behavioral Health Provider Survey_OMB_clean.docx
Yes
Yes
Fillable Fileable
Form and Instruction
Key Informant Interview Case Study
Key Informant Interview Case Study
Att D. Key Informant Interview Guide_OMB_clean.docx
Yes
Yes
Fillable Fileable
Form and Instruction
Key Informant Interview Cost Study
Key Informant Interview Cost Study
Att E_A. Key Informant Interview Guide-Cost_Sub_Study_OMB_clean.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
GLS National Outcomes Evaluation Suicide Prevention Data Center
FR Citation:
75 FR 28264
Number of Respondents:
56
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
168
0
168
0
0
0
Annual IC Time Burden (Hours)
99
0
99
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
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.