HEALTH-RELATED SURVEY, INDIVIDUAL FACILITY REPORT

ICR 198710-0704-001

OMB: 0704-0175

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
108786 Migrated
ICR Details
0704-0175 198710-0704-001
Historical Active 198610-0704-013
DOD/DODDEP
HEALTH-RELATED SURVEY, INDIVIDUAL FACILITY REPORT
Revision of a currently approved collection   No
Regular
Approved without change 02/18/1988
Retrieve Notice of Action (NOA) 10/21/1987
  Inventory as of this Action Requested Previously Approved
12/31/1990 12/31/1990 12/31/1987
1,245 0 1,920
1,245 0 1,920
0 0 0

INFORMATION IS COLLECTED TO ASSIGN SOLDIERS TO AREAS WHERE THEY CAN RECEIVE SERVICES FOR THEIR EXCEPTIONAL FAMILY MEMBERS.

None
None


No

1
IC Title Form No. Form Name
HEALTH-RELATED SURVEY, INDIVIDUAL FACILITY REPORT DA 4723-2-R

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,245 1,920 0 -675 0 0
Annual Time Burden (Hours) 1,245 1,920 0 -675 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$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.
10/21/1987


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