Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Behavioral Health Consultation Provider Semi-Structured Interview (SSI) Modified 67 50 0 Form and Instruction 1I Attachment 1I - Behavioral Health Consultation Provider SSI PMHCA
Form and Instruction 1A Attachment 1A - Behavioral Health Consultation Provider SSI MMHSUD
Form and Instruction 1A 1A_MCHB_0906-0105_MMHSUD BH Consultation Provider SSI_Redline
Form and Instruction 1I 1I_MCHB_0906-0105_PMHCA BH Consultation Provider SSI_Redline
Care Coordinator Semi-Structured Interview (SSI) Modified 67 50 0 Form and Instruction 1J Attachment 1J - Care Coordinator SSI PMHCA
Form and Instruction 1B Attachment 1B - Care Coordinator SSI MMHSUD
Form and Instruction 1B 1B_MCHB_0906-0105_MMHSUD Care Coordinator SSI_Redline
Form and Instruction 1J 1J_MCHB_0906-0105_PMHCA Care Coordinator SSI_Redline
Champion Semi-Structured Interview Modified 67 34 0 Form and Instruction 1K Attachment 1K - Champion SSI PMHCA
Form and Instruction 1C Attachment 1C - Champion SSI MMHSUD
Form and Instruction 1C 1C_MCHB_0906-0105_MMHSUD Champion SSI_Redline
Form and Instruction 1K 1K_MCHB_0906-0105_PMHCA Champion SSI_Redline.docx
Community-based and Other Resources Semi-Structured Interview (SSI) Modified 50 25 0 Form and Instruction 1L Attachment 1L - Community-Based and Other Resources SSI PMHCA
Form and Instruction 1D Attachment 1D - Community-Based and Other Resources SSI MMHSUD
Form and Instruction 1D 1D_MCHB_0906-0105_MMHSUD Community Resources SSI_Redline
Form and Instruction 1L 1L_MCHB_0906-0105_PMHCA Community Resources SSI_Redline
Health Professional Survey Modified 23256 7674 0 Form and Instruction 1M Attachment 1M - Health Professional Survey PMHCA
Form and Instruction 1E Attachment 1E - Health Professional Survey MMHSUD
Form and Instruction 1E 1E_MCHB_0906-0105_MMHSUD Health Professional Survey_Redline
Form and Instruction 1M 1M_MCHB_0906-0105_MCHB_PMHCA Health Professional Survey_Redline
Practice-Level Survey Modified 6172 2037 0 Form and Instruction 1N Attachment 1N - Practice Level Survey PMHCA
Form and Instruction 1F Attachment 1F - Practice Level Survey MMHSUD
Form and Instruction 1F 1F_MCHB_0906-0105_MMHSUD Practice Level Survey_Redline
Form and Instruction 1N 1N_MCHB_0906-0105_MCHB_PMHCA Practice Level Survey_Redline
Program Implementation Semi-Structured Interview (SSI) Modified 134 134 0 Form and Instruction 1O Attachment 1O - Program Implementation SSI PMHCA
Form and Instruction 1G Attachment 1G - Program Implementation SSI MMHSUD
Form and Instruction 1G 1G_MCHB_0906-0105_MMHSUD Program Implementation SSI_Redline
Form and Instruction 1O 1O_MCHB_0906-0105_MCHB_PMHCA Program Implementation SSI_Redline
Program Implementation Survey Modified 67 22 0 Form and Instruction 1P Attachment 1P - Program Implementation Survey PMHCA
Form and Instruction 1H Attachment 1H - Program Implementation Survey MMHSUD
Form and Instruction 1H 1H_MCHB_0906-0105_MMHSUD Program Implementation Survey_Redline
Form and Instruction 1P 1P_MCHB_0906-0105_PMHCA Program Implementation Survey_Redline
Total burden requested under this ICR: 29880 10026 0  
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