NUTRITIONAL ASSESSMENT OF DIETARY INTAKE

ICR 199402-0701-001

OMB: 0701-0130

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
107984 Migrated
ICR Details
0701-0130 199402-0701-001
Historical Active
DOD/AF
NUTRITIONAL ASSESSMENT OF DIETARY INTAKE
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 05/16/1994
Retrieve Notice of Action (NOA) 02/28/1994
  Inventory as of this Action Requested Previously Approved
05/31/1997 05/31/1997
12,000 0 0
3,000 0 0
0 0 0

AF FORM 2572 IS USED TO RECORD FOOD INTAKE ON ALL INPATIENTS AND SOME OUTPATIENTS RECEIVING THERAPEUTIC DIETS AND THOSE RECEIVING A REGULAR DIET WHEN REQUESTED BY THE HEALTH CARE PROVIDER. THE DIET COUNSELOR ANALYZES THE INFORMATION, RECORDS THE ANALYSIS ON THE REVERSE SIDE OF THE FORM, WRITES A PROGRESS NOTE TO THE PHYSICIAN, AND FILES THE AF 25 IN THE PATIENT'S MEDICAL RECORD.

None
None


No

1
IC Title Form No. Form Name
NUTRITIONAL ASSESSMENT OF DIETARY INTAKE AF 2572

  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 12,000 0 0 12,000 0 0
Annual Time Burden (Hours) 3,000 0 0 3,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
02/28/1994


© 2024 OMB.report | Privacy Policy