Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Behavioral Health Consultation Provider Semi-Structured Interview (SSI) New 67 50 0 Form and Instruction B8 Attachment B8 - Behavioral Health Consultation Provider SSI PMHCA
Form and Instruction B16 Attachment B16 - Behavioral Health Consultation Provider SSI MMHSUD
Care Coordinator Semi-Structured Interview (SSI) New 67 50 0 Form and Instruction B5 Attachment B5 - Care Coordinator SSI PMHCA
Form and Instruction B13 Attachment B13 - Care Coordinator SSI MMHSUD
Champion Semi-Structured Interview New 67 34 0 Form and Instruction B7 Attachment B7 - Champion SSI PMHCA
Form and Instruction B15 Attachment B15 - Champion SSI MMHSUD
Community-based and Other Resources Semi-Structured Interview (SSI) New 50 25 0 Form and Instruction B6 Attachment B6 - Community-Based and Other Resources SSI PMHCA
Form and Instruction B14 Attachment B14 - Community-Based and Other Resources SSI MMHSUD
Health Professional Survey New 23256 7674 0 Form and Instruction B1 Attachment B1 - Health Professional Survey PMHCA
Form and Instruction B9 Attachment B9 - Health Professional Survey MMHSUD
Practice-Level Survey New 6172 2037 0 Form and Instruction B2 Attachment B2 - Practice Level Survey PMHCA
Form and Instruction B10 Attachment B10 - Practice Level Survey MMHSUD
Program Implementation Semi-Structured Interview (SSI) New 134 134 0 Form and Instruction B4 Attachment B4 - Program Implementation SSI PMHCA
Form and Instruction B12 Attachment B12 - Program Implementation SSI MMHSUD
Program Implementation Survey New 67 22 0 Form and Instruction B3 Attachment B3 - Program Implementation Survey PMHCA
Form and Instruction B11 Attachment B11 - Program Implementation Survey MMHSUD
Total burden requested under this ICR: 29880 10026 0  
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