Information Collection

HC Adult SAQ that includes Mental Health Questions

IC 236894 under ICR 202007-0935-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HC Adult SAQ that includes Mental Health Questions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	Approved	Previously Approved
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

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.