Health Status Review/Report of Medical Exam

Health Status Review/Report of Medical Exam

OMB: 0420-0510

IC ID: 916

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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 PC-1790 Yes Yes
Form PC-1789 Yes Yes


    

12,500 0
   
Individuals or Households
 
   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

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

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