Medical Information Questionnaire

ICR 200501-0704-003

OMB: 0704-0206

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
5291 Migrated
ICR Details
0704-0206 200501-0704-003
Historical Inactive 200304-0704-007
DOD/DODDEP
Medical Information Questionnaire
Revision of a currently approved collection   No
Regular
Withdrawn and continue 05/26/2005
Retrieve Notice of Action (NOA) 01/31/2005
  Inventory as of this Action Requested Previously Approved
05/31/2005 05/31/2008 05/31/2005
11,700 0 11,700
5,850 0 0
0 0 0

This form is used to obtain medical information from records and physicians where there is an indication of history of mental or nervous disorder; use or abuse of prescribed or illegal drugs; or abuse or excessive use of alcohol. DOD 5200.2-R, DOD Personnel Security Program regulation specifics medical information is to be obtained to determine an individual's eligibility for access to classified information, retention in sensitive duties or other designated duties requiring such information. Without complete medical information, a determination of an individual's suitability cannot be made. ...

None
None


No

1
IC Title Form No. Form Name
Medical Information Questionnaire DSS-FL-14A

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.
01/31/2005


© 2024 OMB.report | Privacy Policy