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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