Information Collection

Physician's Statement

IC 157650 under ICR 197908-3220-010 · OMB 3220-0103.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0103 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	PHYSICIAN'S STATEMENT	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

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	G-478				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,000	2,000	1,000
Annual IC Time Burden (Hours)	500	333	167
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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