Information Collection

Mental Health Current Evaluation and Treatment Summary Form

IC 224328 under ICR 201808-0420-004 · OMB 0420-0550.

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 Treatment and Summary Mental Health Treatment and Summary_Revised.docx	Form and Instruction
Justification for revised Mental Health form.docx Non-substantive Change Justification	IC Document

IC Title:

Agency IC Tracking Number:

PC-262-14

IC Status: Modified

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 Treatment and Summary	Mental Health Treatment and Summary_Revised.docx		Yes	No	Paper Only

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
	Requested	Previously Approved
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
Non-substantive Change Justification	Justification for revised Mental Health form.docx	09/11/2018

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