Health Status Review/Report of Medical Exam

Health Status Review/Report of Medical Exam

OMB: 0420-0510

IC ID: 915

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Information Collection (IC) Details

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Health Status Review/Report of Medical Exam
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 1789 No No
Form 1790 No No


    

6,500 0
   
Individuals or Households
 
   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 1 0 1 0 0 0
Annual IC Time Burden (Hours) 1,625 0 1,625 0 0 0
Annual IC Cost Burden (Dollars) 616,000 0 616,000 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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