MEDICAL INFORMATION QUESTIONNAIRE

ICR 199107-0704-007

OMB: 0704-0206

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
108856 Migrated
ICR Details
0704-0206 199107-0704-007
Historical Active 198410-0704-001
DOD/DODDEP
MEDICAL INFORMATION QUESTIONNAIRE
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 10/09/1991
Retrieve Notice of Action (NOA) 07/24/1991
  Inventory as of this Action Requested Previously Approved
10/31/1994 10/31/1994
15,206 0 0
9,124 0 0
0 0 0

THIS FORM IS USED TO GATHER MEDICAL INFORMATION REGARDING THE SUBJECT A PERSONNEL SECURITY INVESTIGATION (PSI). A PSI IS CONDUCTED ON DOD PERSONNEL WHO REQUIRE ACCESS TO CLASSIFIED INFORMATION TO DETERMINE THEIR ELIGIBILITY FOR ACCESS TO CLASSIFIED INFORMATION, FOR RETENTION IN SENSITIVE DUTIES, OR OTHER DESIGNATED DUTIES REQUIRING SUCH

None
None


No

1
IC Title Form No. Form Name
MEDICAL INFORMATION QUESTIONNAIRE DIS FORM, LETTER 14A

  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 15,206 0 0 0 15,206 0
Annual Time Burden (Hours) 9,124 0 0 0 9,124 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
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.
07/24/1991


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