Information Collection

HC Adult SAQ that includes Mental Health Questions

IC 236894 under ICR 201907-0935-002 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 106a HC Adult SAQ that includes Mental Health Questions	Form and Instruction
106a Attachment 106a.REV_Female PSAQ with Mental Health Conte Attachment 106a.REV_Female PSAQ with Mental Health Content_for OMB.pdf	Form and Instruction
106b Attachment106b.REV_Male PSAQ with Mental Health Content Attachment106b.REV_Male PSAQ with Mental Health Content_for OMB.pdf	Form and Instruction

IC Title:

HC Adult SAQ that includes Mental Health Questions

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	106a	Attachment 106a.REV_Female PSAQ with Mental Health Content	Attachment 106a.REV_Female PSAQ with Mental Health Content_for OMB.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	106b	Attachment106b.REV_Male PSAQ with Mental Health Content	Attachment106b.REV_Male PSAQ with Mental Health Content_for OMB.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20,476

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20,476	20,476
Annual IC Time Burden (Hours)	1,194	1,194
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.