Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Case Coordinator Questionnaire (Form M-13E) - Recordkeeping New 32 32 0 Form and Instruction Form M-13E Case Coordinator Questionnaire
Case Coordinator Questionnaire (Form M-13E) - Respondents New 108 108 0 Form and Instruction Form M-13E Case Coordinator Questionnaire
Checklist for a Child-Friendly Environment (Form M-4A to M4B) New 2592 648 0 Form and Instruction Form M-4A Checklist for a Child-Friendly Environment - Care Provider Facility
Form and Instruction Form M-4B Checklist for a Child-Friendly Environment - Individual Foster Home
Corrective Action Report (Form M-1) - Recordkeeping New 100 2200 0 Form and Instruction M-1 Corrective Action Report (Form M-1)
Corrective Action Report (Form M-1) - Respondents New 108 540 0 Form and Instruction M-1 Corrective Action Report (Form M-1)
FFS Compliance and Safety Site Visit Report (Form M-3A) - Recordkeeping New 28 336 0 Form and Instruction Form M-3A FFS Compliance and Safety Site Visit Report
FFS Compliance and Safety Site Visit Report (Form M-3A) - Respondents New 2592 2592 0 Form and Instruction Form M-3A FFS Compliance and Safety Site Visit Report
Foster Home On Site Monitoring Checklist (Form M-9B) New 8 4 0 Form and Instruction Form M-9 Foster Home On Site Monitoring Checklist
HS/PRS Site Visit Guide (Form M-7E) - Recordkeeping New 8 168 0 Form and Instruction Form M-7E HS PRS Site Visit Guide
HS/PRS Site Visit Guide (Form M-7E) - Respondents New 30 180 0 Form and Instruction Form M-7E HS PRS Site Visit Guide
Home Study and Post-Release Services Case File Checklist (Form M-8C) - Recordkeeping New 44 44 0 Form and Instruction Form M-8C Home Study and Post-Release Services Case File Checklist
Home Study and Post-Release Services Case File Checklist (Form M-8C) - Respondents New 150 150 0 Form and Instruction Form M-8C Home Study and Post-Release Services Case File Checklist
Home Study and Post-Release Services Caseworker Questionnaire (Form M-13B) - Recordkeeping New 24 24 0 Form and Instruction Form M-13B Home Study and Post-Release Services Caseworker Questionnaire
Home Study and Post-Release Services Caseworker Questionnaire (Form M-13B) - Respondents New 90 90 0 Form and Instruction Form M-13B Home Study and Post-Release Services Caseworker Questionnaire
Home Study and Post-Release Services Director Questionnaire (Form M-13A) - Recordkeeping New 8 4 0 Form and Instruction Form M-13A 48 - HS PRS Program Director Questionnaire
Home Study and Post-Release Services Director Questionnaire (Form M-13A) - Respondents New 30 30 0 Form and Instruction Form M-13A HS PRS Program Director Questionnaire
Home Study and Post-Release Services Personnel File Checklist (Form M-10C) New 24 24 0 Form and Instruction Form M-10C Home Study and Post-Release Services Personnel File Checklist
Incident Reviews (Forms M-5A to M-5B) New 65 97 0 Form and Instruction Form M-5A UAC Incident Review
Form and Instruction Form M-5B Adult Incident Review
LTFC Monitoring and LTFC Remote Monitoring Notes (Forms M-6C to M-6D) New 4 48 0 Form and Instruction Form M-6C LTFC Monitoring Notes
Form and Instruction Form M-6D LTFC Remote Monitoring Notes
LTFC Site Visit and LTFC Remote Monitoring Site Visit Guides (Forms M-7C to M-7D) - Recordkeeping New 4 84 0 Form and Instruction Form M-7C LTFC Site Visit Guide
Form and Instruction Form M-7D LTFC Remote Site Visit Guide
LTFC Site Visit and LTFC Remote Monitoring Site Visit Guides (Forms M-7C to M-7D) - Respondents New 15 90 0 Form and Instruction Form M-7C LTFC Site Visit Guide
Form and Instruction Form M-7D LTFC Remote Site Visit Guide
Legal Service Provider Questionnaire (Form M-13C) - Recordkeeping New 28 28 0 Form and Instruction Form M-13C Legal Service Provider Questionnaire
Legal Service Provider Questionnaire (Form M-13C) - Respondents New 93 93 0 Form and Instruction Form M-13C Legal Service Provider Questionnaire
Long Term Foster Care Client Questionnaire (M-12C) - Recordkeeping New 20 10 0 Form and Instruction Form M-12C LTFC Client Questionnaire
Long Term Foster Care Client Questionnaire (M-12C) - Respondents New 75 38 0 Form and Instruction Form M-12C LTFC Client Questionnaire
Long Term Foster Care File Checklist (Form M-8B) - Recordkeeping New 20 60 0 Form and Instruction Form M-8B Long Term Foster Care File Checklist
Long Term Foster Care File Checklist (Form M-8B) - Respondents New 75 75 0 Form and Instruction Form M-8B Long Term Foster Care File Checklist
Long Term Foster Care Foster Parent Checklist (Form M-10D) New 8 4 0 Form and Instruction Form M-10D Long Term Foster Care Foster Parent Checklist
Long Term Foster Care Foster Parent Questionnaire (form M-11O) - Recordkeeping New 8 6 0 Form and Instruction Form M-11O LTFC Foster Parent Questionnaire
Long Term Foster Care Foster Parent Questionnaire (form M-11O) - Respondents New 30 23 0 Form and Instruction Form M-11O LTFC Foster Parent Questionnaire
Long Term Foster Care Home Finder Questionnaire (Form M-11M) - Recordkeeping New 4 4 0 Form and Instruction Form M-11M Long Term Foster Care Home Finder Questionnaire
Long Term Foster Care Home Finder Questionnaire (Form M-11M) - Respondents New 15 15 0 Form and Instruction Form M-11M Long Term Foster Care Home Finder Questionnaire
Long Term Foster Care Independent Living Life Skills Staff Questionnaire (Form M-11N) - Recordkeeping New 4 4 0 Form and Instruction Form M-11N Long Term Foster Care Independent Living Life Skills Staff Questionnaire
Long Term Foster Care Independent Living Life Skills Staff Questionnaire (Form M-11N) - Respondents New 15 15 0 Form and Instruction Form M-11N Long Term Foster Care Independent Living Life Skills Staff Questionnaire
Long Term Foster Care Legal Service Provider Questionnaire (Form M-13D) - Recordkeeping New 4 3 0 Form and Instruction Form M-13D LTFC Legal Service Provider Questionnaire
Long Term Foster Care Legal Service Provider Questionnaire (Form M-13D) - Reporting New 15 11 0 Form and Instruction Form M-13D LTFC Legal Service Provider Questionnaire
Monitoring Schedule (Form M-15) New 1 0 0 Form and Instruction Form M-15 Monitoring Schedule
Monitoring Visit (Form M-14) New 32 16 0 Form and Instruction Form M-14 Monitoring Visit
Monitoring and Remote Monitoring Notes (Forms M-6A to M-6B) New 28 336 0 Form and Instruction Form M-6A Monitoring Notes
Form and Instruction Form M-6B Remote Monitoring Notes
On Site Monitoring Checklist (Form M-9A) New 28 112 0 Form and Instruction Form M-9A On Site Monitoring Checklist
Out-of-Network Site Visit Report (Form M-3B) New 120 120 0 Form and Instruction Form M-3B Out-of-Network Site Visit Report
Personnel File Checklist (Form M-10A) New 124 124 0 Form and Instruction Form M-10A Personnel File Checklist
Post-Release Services Home Observation (Form M-9C) New 16 8 0 Form and Instruction Form M-9C Post-Release Services Home Observation
Program Staff Questionnaires (Form M-11A-K) - Recordkeeping New 216 216 0 Form and Instruction Form M-11A Program Director Questionnaire
Form and Instruction Form M-11B LTFC Program Director Questionnaire
Form and Instruction Form M-11C Clinician Questionnaire
Form and Instruction Form M-11D LTFC Clinician Questionnaire
Form and Instruction Form M-11E Case Manager Questionnaire
Form and Instruction Form M-11F LTFC Case Manager Questionnaire
Form and Instruction Form M-11G Education Staff Questionnaire
Form and Instruction Form M-11H LTFC Educational Staff Questionnaire
Form and Instruction Form M-11I Medical Coordinator Questionnaire
Form and Instruction Form M-11J Youth Care Worker Questionnaire
Form and Instruction Form M-11K PSA Compliance Manager Questionnaire
Program Staff Questionnaires (Form M-11A-K) - Respondents New 756 756 0 Form and Instruction Form M-11A Program Director Questionnaire
Form and Instruction Form M-11B LTFC Program Director Questionnaire
Form and Instruction Form M-11C Clinician Questionnaire
Form and Instruction Form M-11D LTFC Clinician Questionnaire
Form and Instruction Form M-11E Case Manager Questionnaire
Form and Instruction Form M-11F LTFC Case Manager Questionnaire
Form and Instruction Form M-11G Education Staff Questionnaire
Form and Instruction Form M-11H LTFC Educational Staff Questionnaire
Form and Instruction Form M-11I Medical Coordinator Questionnaire
Form and Instruction Form M-11J Youth Care Worker Questionnaire
Form and Instruction Form M-11K PSA Compliance Manager Questionnaire
Secure Client Questionnaire (Form M-12D) - Recordkeeping New 2 1 0 Form and Instruction Form M-12D Secure Client Questionnaire
Secure Client Questionnaire (Form M-12D) - Respondents New 5 3 0 Form and Instruction Form M-12D Secure Client Questionnaire
Secure Detention Officer Questionnaire (Form M-11L) - Recordkeeping New 0 0 0 Form and Instruction Form M-11L Secure Detention Officer Questionnaire
Secure Detention Officer Questionnaire (Form M-11L) - Respondents New 1 1 0 Form and Instruction Form M-11L Secure Detention Officer Questionnaire
Secure and Staff Secure Addendum to Case File Checklist (Form M-8D) - Recordkeeping New 4 4 0 Form and Instruction Form M-8D Secure and Staff Secure Addendum to Case File Checklist
Secure and Staff Secure Addendum to Case File Checklist (Form M-8D) - Respondents New 20 20 0 Form and Instruction Form M-8D Secure and Staff Secure Addendum to Case File Checklist
Site Visit and Remote Monitoring Site Visit Guides (Forms M-7A to M-7B) - Recordkeeping New 28 784 0 Form and Instruction Form M-7A Site Visit Guide
Form and Instruction Form M-7B Remote Monitoring Site Visit Guide
Site Visit and Remote Monitoring Site Visit Guides (Forms M-7A to M-7B) - Respondents New 93 1116 0 Form and Instruction Form M-7A Site Visit Guide
Form and Instruction Form M-7B Remote Monitoring Site Visit Guide
Supplement to Personnel File Checklist (Form M-10B) New 216 216 0 Form and Instruction Form M-10B Supplement to Personnel File Checklist
UAC Case File Checklist (Form M-8A) - Recordkeeping New 132 792 0 Form and Instruction Form M-8A UAC Case File Checklist
UAC Case File Checklist (Form M-8A) - Respondents New 465 465 0 Form and Instruction Form M-8A UAC Case File Checklist
UAC Questionnaires (Forms M-12A-B) - Recordkeeping New 132 66 0 Form and Instruction Form M-12A UAC Questionnaire - Ages 6-12 Years Old
Form and Instruction Form M-12B UAC Questionnaire - Ages 13 and Older
UAC Questionnaires (Forms M-12A-B) - Respondents New 460 230 0 Form and Instruction Form M-12A UAC Questionnaire - Ages 6-12 Years Old
Form and Instruction Form M-12B UAC Questionnaire - Ages 13 and Older
Voluntary Agency Site Visit Guide (Form M-7F) - Recordkeeping New 2 56 0 Form and Instruction Form M-7F Voluntary Agency Site Visit Guide
Voluntary Agency Site Visit Guide (Form M-7F) - Respondents New 5 40 0 Form and Instruction Form M-7F Voluntary Agency Site Visit Guide
Total burden requested under this ICR: 9364 13364 0  
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