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Health-related Survey, Individual Facility Report
HEALTH-RELATED SURVEY, INDIVIDUAL FACILITY REPORT
OMB: 0704-0175
IC ID: 108785
OMB.report
DOD/DODDEP
OMB 0704-0175
ICR 198410-0704-002
IC 108785
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0175 can be found here:
1995-05-08 - Reinstatement without change of a previously approved collection
1991-03-25 - Reinstatement with change of a previously approved collection
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:
HEALTH-RELATED SURVEY, INDIVIDUAL FACILITY REPORT
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
DA 4723-2-R
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
2,355
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
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
2,355
0
0
165
0
2,190
Annual IC Time Burden (Hours)
2,355
0
0
910
0
1,445
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.