Information Collection

School Based Mental Health Application

IC 254613 under ICR 202207-1810-005 · OMB 1810-0773.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1810-0773 can be found here:

Documents and Forms

Document Name Document Type
School Based Mental Health Application Form and Instruction
1810-new_SMBH Application Package_7-29.docx Form and Instruction
1810-new_84.184H SBMH Application Package.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	School Based Mental Health Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	N/A	N/A	1810-new_84.184H SBMH Application Package.docx		Yes	Yes	Fillable Fileable

Line of Business: Education

Subfunction: Elementary, Secondary, and Vocational Education

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	12,000	12,000
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.