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Health Status Review/Report of Medical Exam
Health Status Review/Report of Medical Exam
OMB: 0420-0510
IC ID: 916
OMB.report
PEACE
OMB 0420-0510
ICR 200011-0420-001
IC 916
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0420-0510 can be found here:
2024-08-23 - Reinstatement without change of a previously approved collection
2020-11-17 - Reinstatement without change of a previously approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Health Status Review/Report of Medical Exam
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
PC-1790
Yes
Yes
Form
PC-1789
Yes
Yes
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
12,500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
12 %
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
12,500
0
12,499
0
0
1
Annual IC Time Burden (Hours)
4,625
0
3,000
0
0
1,625
Annual IC Cost Burden (Dollars)
16,000
0
0
-600,000
0
616,000
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.