Information Collection

Mental Health Assessment Form - Recordkeeping Time if obtained via health records

IC 283126 under ICR 202609-0970-009 · OMB 0970-0509.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Mental Health Assessment Form Mental Health Assessment Form - Recordkeeping Time if obtained via health records	Form
1 Mental Health Assessment Form Mental Health Assessment Form_Clean_9.30.26.docx	Form
Dear Colleague Letter - Mental Health Assessment Form_clean_9.30.26.docx Dear Colleague MHAF Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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				Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: 09-80-0321 ORR Unaccompanied Children Bureau Administrative Program Records

FR Citation: 89 FR 100500

Number of Respondents: 150

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	660	660
Annual IC Time Burden (Hours)	139	139
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Dear Colleague MHAF Letter		10/18/2026

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

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