Information Collection

Medical Information Questionnaire Dis Fl 14 And 14a

IC 108855 under ICR 198410-0704-001 · OMB 0704-0206.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	MEDICAL INFORMATION QUESTIONNAIRE DIS FL 14 AND 14A	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.	Available Electronically?	Can Be Submitted Electronically?
Form	DIS FORM	No	No
Form	LETTER	No	No
Form	14 & 14A	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	14,000	14,000
Annual IC Time Burden (Hours)	7,000	7,000
Annual IC Cost Burden (Dollars)	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.