Information Collection

Request for Examination and/or Treatment

IC 13712 under ICR 200209-1215-003 · OMB 1215-0066.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0066 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Request for Examination and/or Treatment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-1				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	109,725	-5,775	115,500
Annual IC Time Burden (Hours)	118,503	-6,237	124,740
Annual IC Cost Burden (Dollars)	44,000	2,000	42,000

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.