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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Case Coordinator Questionnaire (Form M-13E) - Recordkeeping
Unchanged
32
32
0
Form and Instruction
Form M-13E
Case Coordinator Questionnaire
Case Coordinator Questionnaire (Form M-13E) - Respondents
Unchanged
108
108
0
Form and Instruction
Form M-13E
Case Coordinator Questionnaire
Checklist for a Child-Friendly Environment (Form M-4A to M4B)
Unchanged
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
Unchanged
100
2200
0
Form and Instruction
M-1
Corrective Action Report (Form M-1)
Corrective Action Report (Form M-1) - Respondents
Unchanged
108
540
0
Form and Instruction
M-1
Corrective Action Report (Form M-1)
FFS Compliance and Safety Site Visit Report (Form M-3A) - Respondents
Unchanged
2592
2592
0
Form and Instruction
Form M-3A
FFS Compliance and Safety Site Visit Report
HS/PRS Site Visit Guide (Form M-7E) - Recordkeeping
Unchanged
8
168
0
Form and Instruction
Form M-7E
HS PRS Site Visit Guide
HS/PRS Site Visit Guide (Form M-7E) - Respondents
Unchanged
30
180
0
Form and Instruction
Form M-7E
HS PRS Site Visit Guide
Home Study and Post-Release Services Caseworker Questionnaire (Form M-13B) - Recordkeeping
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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)
Unchanged
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)
Unchanged
65
97
0
Form and Instruction
Form M-5A
UC Incident Review
Form and Instruction
Form M-5B
Adult Incident Review
Interpreter Questionnaire (Form M-11P)
New
230
115
0
Form and Instruction
Form M-11P
Interpreter Questionnaire
LTFC Site Visit and LTFC Remote Monitoring Site Visit Guides (Forms M-7C to M-7D) - Recordkeeping
Unchanged
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
Unchanged
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
Unchanged
28
28
0
Form and Instruction
Form M-13C
Legal Service Provider Questionnaire
Legal Service Provider Questionnaire (Form M-13C) - Respondents
Unchanged
93
93
0
Form and Instruction
Form M-13C
Legal Service Provider Questionnaire
Long Term Foster Care Client Questionnaire (M-12C) - Recordkeeping
Unchanged
20
10
0
Form and Instruction
Form M-12C
LTFC Client Questionnaire
Long Term Foster Care Client Questionnaire (M-12C) - Respondents
Unchanged
75
38
0
Form and Instruction
Form M-12C
LTFC Client Questionnaire
Long Term Foster Care Foster Parent Checklist (Form M-10D)
Unchanged
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
Unchanged
8
6
0
Form and Instruction
Form M-11O
LTFC Foster Parent Questionnaire
Long Term Foster Care Foster Parent Questionnaire (form M-11O) - Respondents
Unchanged
30
23
0
Form and Instruction
Form M-11O
LTFC Foster Parent Questionnaire
Long Term Foster Care Home Finder Questionnaire (Form M-11M) - Recordkeeping
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
15
11
0
Form and Instruction
Form M-13D
LTFC Legal Service Provider Questionnaire
Monitoring Schedule (Form M-15)
Unchanged
1
0
0
Form and Instruction
Form M-15
Monitoring Schedule
Monitoring Visit (Form M-14)
Unchanged
32
16
0
Form and Instruction
Form M-14
Monitoring Visit
Out-of-Network Site Visit Report (Form M-3B)
Unchanged
120
120
0
Form and Instruction
Form M-3B
Out-of-Network Site Visit Report
Personnel File Checklist (Form M-10A)
Unchanged
124
124
0
Form and Instruction
Form M-10A
Personnel File Checklist
Program Staff Questionnaires (Form M-11A-K) - Recordkeeping
Unchanged
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
Unchanged
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
Unchanged
2
1
0
Form and Instruction
Form M-12D
Secure Client Questionnaire
Secure Client Questionnaire (Form M-12D) - Respondents
Unchanged
5
3
0
Form and Instruction
Form M-12D
Secure Client Questionnaire
Secure Detention Officer Questionnaire (Form M-11L) - Recordkeeping
Unchanged
0
0
0
Form and Instruction
Form M-11L
Secure Detention Officer Questionnaire
Secure Detention Officer Questionnaire (Form M-11L) - Respondents
Unchanged
1
1
0
Form and Instruction
Form M-11L
Secure Detention Officer Questionnaire
Site Visit and Remote Monitoring Site Visit Guides (Forms M-7A to M-7B) - Recordkeeping
Unchanged
28
812
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
Unchanged
93
1209
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)
Unchanged
216
216
0
Form and Instruction
Form M-10B
Supplement to Personnel File Checklist
UC Questionnaires (Forms M-12A-B, E) - Recordkeeping
Unchanged
132
66
0
Form and Instruction
Form M-12A
UC Questionnaire - Ages 6-12 Years Old - English
Form and Instruction
Form M-12B
UC Questionnaire - Ages 13 and Older - English
Form and Instruction
Form M-12E
UC Questionnaire - Ages 5 and Under - English
Form and Instruction
Form M-12As
UC Questionnaire - Ages 6-12 Years Old - Spanish
Form and Instruction
Form M-12Bs
UC Questionnaire - Ages 13 and Older - Spanish
Form and Instruction
Form M-12Es
UC Questionnaire - Ages 5 and Under - Spanish
UC Questionnaires (Forms M-12A-B, E) - Respondents
Unchanged
460
230
0
Form and Instruction
Form M-12A
UC Questionnaire - Ages 6-12 Years Old - English
Form and Instruction
Form M-12B
UC Questionnaire - Ages 13 and Older - English
Form and Instruction
Form M-12E
UC Questionnaire - Ages 5 and Under - English
Form and Instruction
Form M-12As
UC Questionnaire - Ages 6-12 Years Old - Spanish
Form and Instruction
Form M-12Bs
UC Questionnaire - Ages 13 and Older - Spanish
Form and Instruction
Form M-12Es
UC Questionnaire - Ages 5 and Under - Spanish
Unlicensed Facility Personnel File Checklist (Form M-10A-UF) - Recordkeeping
New
900
900
0
Form and Instruction
Form M-10A-UF
Unlicensed Facility Personnel File Checklist
Unlicensed Facility Case Coordinator Questionnaire (Form M-13E-UF) - Recordkeeping
New
216
216
0
Form and Instruction
Form M-13E-UF
Unlicensed Facility Case Coordinator Questionnaire
Unlicensed Facility Case Coordinator Questionnaire (Form M-13E-UF) - Respondent
New
224
224
0
Form and Instruction
Form M-13E-UF
Unlicensed Facility Case Coordinator Questionnaire
Unlicensed Facility Interpreter Questionnaire (Form M-11P-UF) - Recordkeeping
New
216
108
0
Form and Instruction
Form M-11P-UF
Interpreter Questionnaire
Unlicensed Facility Interpreter Questionnaire (Form M-11P-UF) - Respondents
New
224
112
0
Form and Instruction
Form M-11P-UF
Interpreter Questionnaire
Unlicensed Facility Legal Service Provider Questionnaire (Form M-13C-UF) - Recordkeeping
New
216
162
0
Form and Instruction
Form M-13C-UF
Legal Service Provider Questionnaire
Unlicensed Facility Legal Service Provider Questionnaire (Form M-13C-UF) - Respondent
New
224
168
0
Form and Instruction
Form M-13C-UF
Legal Service Provider Questionnaire
Unlicensed Facility Monitoring Notes (Form M-6A-UF) - Recordkeeping
New
216
2592
0
Form and Instruction
Form M-6A-UF
Unlicensed Facility Monitoring Notes
Unlicensed Facility On-Site Monitoring Checklist (Form M-9A-UF) - Recordkeeping
New
216
864
0
Form and Instruction
Form M-9A-UF
Unlicensed Facility On-Site Monitoring Checklist
Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping
New
1800
1800
0
Form and Instruction
Form M-11A-UF
Program Director Questionnaire
Form and Instruction
Form M-11C-UF
Clinician Questionnaire
Form and Instruction
Form M-11E-UF
Case Manager Questionnaire
Form and Instruction
Form M-11G-UF
Education Staff Questionnaire
Form and Instruction
Form M-11I-UF
Medical Coordinator Questionnaire
Form and Instruction
Form M-11J-UF
Youth Care Worker Questionnaire
Form and Instruction
Form M-11K-UF
PSA Compliance Manager Questionnaire
Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Respondents
New
1792
1792
0
Form and Instruction
Form M-11A-UF
Program Director Questionnaire
Form and Instruction
Form M-11C-UF
Clinician Questionnaire
Form and Instruction
Form M-11E-UF
Case Manager Questionnaire
Form and Instruction
Form M-11G-UF
Education Staff Questionnaire
Form and Instruction
Form M-11I-UF
Medical Coordinator Questionnaire
Form and Instruction
Form M-11J-UF
Youth Care Worker Questionnaire
Form and Instruction
Form M-11K-UF
PSA Compliance Manager Questionnaire
Unlicensed Facility Site Visit Guide (Form M-7A-UF) - Recordkeeping
New
216
6264
0
Form and Instruction
Form M-7A-UF
Unlicensed Facility Site Visit Guide
Unlicensed Facility Site Visit Guide (Form M-7A-UF) - Respondents
New
224
224
0
Form and Instruction
Form M-7A-UF
Unlicensed Facility Site Visit Guide
Unlicensed Facility UC Case File Checklist (Form M-8A-UF) - Recordkeeping
New
1116
6696
0
Form and Instruction
Form M-8A-UF
Unlicensed Facility UC Case File Checklist
Unlicensed Facility UC Case File Checklist (Form M-8A-UF) - Respondents
New
1120
1120
0
Form and Instruction
Form M-8A-UF
Unlicensed Facility UC Case File Checklist
Unlicensed Facility UC Questionnaires (M-12A-UF to M-12B-UF & M-12E-UF) - Recordkeeping
New
1116
558
0
Form and Instruction
Form M-12A-UF
UC Questionnaire - Ages 6-12 Years Old English
Form and Instruction
Form M-12As-UF
UC Questionnaire - Ages 6-12 Years Old Spanish
Form and Instruction
Form M-12B-UF
UC Questionnaire - Ages 13 and Older English
Form and Instruction
Form M-12Bs-UF
UC Questionnaire - Ages 13 and Older Spanish
Form and Instruction
Form M-12E-UF
UC Questionnaire - Ages 5 and Under - English
Form and Instruction
Form M-12Es-UF
UC Questionnaire - Ages 5 and Under Spanish
Unlicensed Facility UC Questionnaires (M-12A-UF to M-12B-UF & M-12E-UF) - Respondents
New
1120
560
0
Form and Instruction
Form M-12A-UF
UC Questionnaire - Ages 6-12 Years Old English
Form and Instruction
Form M-12As-UF
UC Questionnaire - Ages 6-12 Years Old Spanish
Form and Instruction
Form M-12B-UF
UC Questionnaire - Ages 13 and Older English
Form and Instruction
Form M-12Bs-UF
UC Questionnaire - Ages 13 and Older Spanish
Form and Instruction
Form M-12E-UF
UC Questionnaire - Ages 5 and Under - English
Form and Instruction
Form M-12Es-UF
UC Questionnaire - Ages 5 and Under Spanish
Voluntary Agency Site Visit Guide (Form M-7F) - Recordkeeping
Unchanged
2
56
0
Form and Instruction
Form M-7F
Voluntary Agency Site Visit Guide
Voluntary Agency Site Visit Guide (Form M-7F) - Respondents
Unchanged
5
40
0
Form and Instruction
Form M-7F
Voluntary Agency Site Visit Guide
Total burden requested under this ICR:
19728
35506
0
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