Jump to navigation
We are required to collect demographic information on service participants. Your responses will remain confidential and will only be reported in aggregate with those of other participants. OMB No. 0930-0197, Exp. Date 1/31/20.
OMB No. 0930-0197, Exp. Date 1/31/20. The purpose of this form is to inform service delivery and fulfill reporting requirements. It is important to obtain information from all participants to maintain quality of service; however, your participation is voluntary. Public reporting burden for this collection of information is estimated to average 5 minutes per response. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Paperwork Reduction Project, OMB #0930-0197, 1 Choke Cherry Road, OAS, Room 7-1044, Rockville, MD, 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0197.