Information Collection

2022 PMHCA Champion SSI

IC 258761 under ICR 202302-0906-003 · OMB 0906-0074.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5A 2022 PMHCA Champion SSI	Form and Instruction
Form 5A 2022 PMHCA Champion SSI	Form and Instruction
5A 2022 PMHCA Champion SSI Attachment B5 - PMHCA Champion SSI - Copy.docx	Form and Instruction
5A 2022 PMHCA Champion SSI Attachment B5 - PMHCA Champion SSI - Copy.docx	Form and Instruction

IC Title:

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	5A	2022 PMHCA Champion SSI	Attachment B5 - PMHCA Champion SSI - Copy.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	10	10
Annual IC Time Burden (Hours)	5	5
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.