Information Collection

2022 PMHCA Care Coordinator SSI

IC 258763 under ICR 202302-0906-003 · OMB 0906-0074.

Documents and Forms

Document Name Document Type
Form 7A 2022 PMHCA Care Coordinator SSI Form and Instruction
Form 7A 2022 PMHCA Care Coordinator SSI Form and Instruction
7A 2022 PMHCA Care Coordinator SSI Attachment B11 - PMHCA Care Coordinator SSI - Copy.docx Form and Instruction
7A 2022 PMHCA Care Coordinator SSI Attachment B11 - PMHCA Care Coordinator SSI - Copy.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2022 PMHCA Care Coordinator SSI	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	7A	2022 PMHCA Care Coordinator SSI	Attachment B11 - PMHCA Care Coordinator 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: 5	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	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

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.