Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Assessment and Referral Tool Modified 14250 2423 0 Form and Instruction Adult Assessment and Referral Tool Adult Assessment and Referral Tool
Form and Instruction Child Assessment and Referral Tool Child Assessment and Referral Tool
Group Encounter Log Modified 24750 1238 0 Form and Instruction Group Encounter Log Group Encounter Log
Individual/Family Crisis Counseling Services Encounter Log Modified 285000 22800 0 Form and Instruction Individual/Family Services Encounter Log Individual/Family Services Encounter Log
Participant Feedback Form Modified 2000 500 0 Form and Instruction Participant Feedback Form Participant Feedback Form
Service Provider Feedback Form Modified 750 308 0 Form and Instruction Service Provider Feedback Form Service Provider Feedback Form
Weekly Tally Sheet Modified 78000 11700 0 Form and Instruction Weekly Tally Sheet Weekly Tally Sheet
Total burden requested under this ICR: 404750 38969 0  
To view an IC, click on IC Title