Information Collection

SSG Fox SPGP - Baseline Mental Health Screening Checklist

IC 280148 under ICR 202601-2900-003 · OMB 2900-0904.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-317e SSG Fox SPGP - Baseline Mental Health Screening Checklist SSG Fox SPGP - Baseline Mental Health Screening Checklist	Form and Instruction
10-317e SSG Fox SPGP - Baseline Mental Health Screening Checklis VA Form 10-317e_Baseline Mental Health Screening Checklist_SPGP_2026.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

2900-0904

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	10-317e				Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8,100	8,100
Annual IC Time Burden (Hours)	2,700	2,700
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.

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