Information Collection

Mental Health Assessment Form - Recordkeeping Time

IC 261446 under ICR 202309-0970-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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: Unchanged

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	Previously Approved
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.