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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

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.