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Information Collection

Medical Information Questionnaire

IC 5291 under ICR 200501-0704-003 · OMB 0704-0206.

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Information Collection (IC) Details

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Medical Information Questionnaire
 
No Migrated
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form DSS-FL-14A No No


    

11,700 0
   
Individuals or Households
 
   0 %

  Requested 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 11,700 0 0 0 0 11,700
Annual IC Time Burden (Hours) 0 0 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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