View Information Collection (IC)

View Information Collection (IC)

IC Title:	ACF Behavioral Health Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey			Behavioral Health Survey - English - 1.23.23.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	500	0	500	0	0	0
Annual IC Time Burden (Hours)	73	0	73	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	SSA Template - Formative for ACF Program Support - BH survey - clean final draft 1.19.23.docx	02/22/2023
Supporting Statement B	SSB Template - Formative for ACF Program Support- BH survey - clean final draft 1.19.23.docx	02/22/2023
Survey Spanish Version	Behavioral Health Survey - Spanish - 1.24.23.docx	02/22/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.