Authorization for Release of Military Medical Patient Records, for Information Needed to Reconstruct Medical Data, Questionnaire

ICR 200111-3095-003

OMB: 3095-0039

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
3095-0039 200111-3095-003
Historical Active 199910-3095-002
NARA
Authorization for Release of Military Medical Patient Records, for Information Needed to Reconstruct Medical Data, Questionnaire
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 11/14/2001
Retrieve Notice of Action (NOA) 11/14/2001
  Inventory as of this Action Requested Previously Approved
01/31/2003 01/31/2003 12/31/2002
79,800 0 79,800
6,650 0 6,650
0 0 0

This information collection is used by individuals and interested private and public sector agencies in order to obtain information from military service records.

None
None


No

1
IC Title Form No. Form Name
Authorization for Release of Military Medical Patient Records, for Information Needed to Reconstruct Medical Data, Questionnaire NA-FORMS-13036, 13042, 13055, 13075

  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 79,800 79,800 0 0 0 0
Annual Time Burden (Hours) 6,650 6,650 0 0 0 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.
11/14/2001


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