Information Collection

Mental Health Current Evaluation and Treatment Summary Form

IC 224328 under ICR 201611-0420-001 · OMB 0420-0550.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0420-0550 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form PC-262-14 Mental Health Current Evaluation and Treatment Summary Form	Form and Instruction
PC-262-14 Mental Health Current Evaluation and Treatment Summary F MHcurrent_and_MHTX.docx	Form and Instruction

IC Title:

Mental Health Current Evaluation and Treatment Summary Form

Agency IC Tracking Number:

PC-262-14

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	PC-262-14	Mental Health Current Evaluation and Treatment Summary Form	MHcurrent_and_MHTX.docx		Yes	No	Fillable Printable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,221

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	1,221	1,221
Annual IC Time Burden (Hours)	2,137	2,137
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.