CCBHC - Evaluation Clinic Survey

Evaluation of the Certified Community Behavioral Health Clinic Demonstration in Accordance with the Bipartisan Safer Communities Act

Documents and Forms

Document Name Document Type
Attachment E. CCBHC Demo Eval Clinic Survey_OMB.docx Other-Survey
Attachment E. CCBHC Demo Eval Clinic Survey_OMB.docx Attachment E - Client Survey IC Document

Information Collection (IC) Details

IC Title:	CCBHC - Evaluation Clinic Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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			Attachment E. CCBHC Demo Eval Clinic Survey_OMB.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 231	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	231	231
Annual IC Time Burden (Hours)	924	924
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment E - Client Survey	Attachment E. CCBHC Demo Eval Clinic Survey_OMB.docx	10/16/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.