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Request For Certification Of Medical Treatment By Attending Physician
REQUEST FOR CERTIFICATION OF MEDICAL TREATMENT BY ATTENDING PHYSICIAN
OMB: 2900-0035
IC ID: 174108
OMB.report
VA
OMB 2900-0035
ICR 198011-2900-026
IC 174108
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
REQUEST FOR CERTIFICATION OF MEDICAL TREATMENT BY ATTENDING PHYSICIAN
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
FL21-104
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
34,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
32,000
0
-2,000
0
0
34,000
Annual IC Time Burden (Hours)
5,333
0
-334
0
0
5,667
Annual IC Cost Burden (Dollars)
0
0
0
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.