Information Collection

Request for Examination and/or Treatment

IC 13713 under ICR 200505-1215-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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: 16,200	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	101,250	-8,475	109,725
Annual IC Time Burden (Hours)	109,350	-9,153	118,503
Annual IC Cost Burden (Dollars)	41,000	-3,000	44,000

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.