Information Collection

Supplemental Mental Health Telephone Questionaire

IC 210239 under ICR 201401-0925-009 · OMB 0925-0626.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Supplemental Mental Health Telephone Questionaire	Form and Instruction
1 Supplemental Mental Health Questionnaire Att_06 Supplemental Mental Health Questionnaire_12042013.pdf	Form and Instruction
Att_05 Supplemental Mental Health Telephone Script.pdf Att_05 Supplemental Mental Health Telephone Script	IC Document
Att_07 Supplemental Mental Health Questionnaire Thank You Letter.pdf Att_07 Supplemental Mental Health Questionnaire Thank You Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Supplemental Mental Health Questionnaire	Att_06 Supplemental Mental Health Questionnaire_12042013.pdf		Yes	Yes	Fillable Fileable

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	18,400	18,400
Annual IC Time Burden (Hours)	4,600	4,600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att_05 Supplemental Mental Health Telephone Script	Att_05 Supplemental Mental Health Telephone Script.pdf	01/29/2014
Att_07 Supplemental Mental Health Questionnaire Thank You Letter	Att_07 Supplemental Mental Health Questionnaire Thank You Letter.pdf	01/29/2014

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