Information Collection

Behavioral Health and Wellness Program (BHWP) Referral Form

IC 258446 under ICR 202301-1076-001 · OMB 1076-0122.

Documents and Forms

Document Name Document Type
Behavioral Health and Wellness Program (BHWP) Referral Form Form and Instruction
BIE BHWP Referral Form Updated BHWP Referral Form 2.6.23.docx www.bia.gov/policy-forms/online-forms/paperwork-reduction-act Form and Instruction
BIE BHWP Referral Form Updated BHWP Referral Form 2.6.23.docx www.bia.gov/policy-forms/online-forms/paperwork-reduction-act Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Behavioral Health and Wellness Program (BHWP) Referral Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 25 CFR 43

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	N/A	BIE BHWP Referral Form	Updated BHWP Referral Form 2.6.23.docx	https://www.bia.gov/policy-forms/online-forms/paperwork-reduction-act	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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