JOB CORPS HEALTH QUESTIONNAIRE

ICR 198610-1205-005

OMB: 1205-0033

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
120659 Migrated
ICR Details
1205-0033 198610-1205-005
Historical Inactive 198605-1205-002
DOL/ETA
JOB CORPS HEALTH QUESTIONNAIRE
Revision of a currently approved collection   No
Regular
Withdrawn and continue 12/17/1986
Retrieve Notice of Action (NOA) 10/22/1986
Form withdrawn at request of agency.
  Inventory as of this Action Requested Previously Approved
07/31/1989 07/31/1989 07/31/1989
18,000 0 18,000
5,940 0 5,940
0 0 0

THE HEALTH QUESTIONNAIRE IS USED TO OBTAIN THE HEALTH HISTORY OF APPLICANTS TO TH PROGRAM TO DETERMINE MEDICAL ELIGIBILITY. THE APPLICANT MUST NOT HAVE A HEALTH CONDITION WHICH REPRESENTS A POTENTIALLY SERIOUS HAZARD TO TH YOUTH OR OTHERS, RESULTS IN A SIGNIFICANT INTERFERENCE IN THE NORMAL PERFORMANCE OF DUTIES, OR REQUIRES FREQUENT EXPENSIVE, OR PROLONGED TREATMENT.

None
None


No

1
IC Title Form No. Form Name
JOB CORPS HEALTH QUESTIONNAIRE ETA 6-53

No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/22/1986


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