Information Collection

Mental Health Assessment Form - Recordkeeping Time

IC 261446 under ICR 202308-0970-003 · OMB 0970-0509.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0509 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Mental Health Assessment Form - Recordkeeping Time	Form
1 Mental Health Assessment Form ORR Mental Health Assessment Form.docx	Form
1 Mental Health Assessment Form ORR Mental Health Assessment Form.docx	Form
Attachment B_Mental Health Assessment Form Instructional Letter for Mental Health Providers.docx Attachment B - Mental Health Assessment Form Instructional Letter for Mental Health Providers	IC Document
Attachment B_Mental Health Assessment Form Instructional Letter for Mental Health Providers.docx Attachment B - Mental Health Assessment Form Instructional Letter for Mental Health Providers	IC Document

IC Title:

Mental Health Assessment Form - Recordkeeping Time

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	1	Mental Health Assessment Form	ORR Mental Health Assessment Form.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: ORR Division of Children's Services Records

FR Citation: 81 FR 46682

Number of Respondents: 500

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,400	3,400
Annual IC Time Burden (Hours)	714	714
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B - Mental Health Assessment Form Instructional Letter for Mental Health Providers	Attachment B_Mental Health Assessment Form Instructional Letter for Mental Health Providers.docx	08/03/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.