Information Collection

Mental Health Referral (Form MH-5)

IC 249545 under ICR 202109-0970-021 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form MH-5 Mental Health Referral (Form MH-5)	Form and Instruction
Form MH-5 Mental Health Referral Mental Health Referral (Form MH-5).pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	Form MH-5	Mental Health Referral	Mental Health Referral (Form MH-5).pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: 09-80-0321 ORR Division of Children's Services Records

FR Citation: 81 FR 46682

Number of Respondents: 216

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,184	5,184
Annual IC Time Burden (Hours)	3,888	3,888
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.