Information Collection

Health Survey--Former Active Duty Marines and Navy Personnel-Camp Lejeune

IC 192932 under ICR 201005-0923-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Health Survey--Former Active Duty Marines and Navy Personnel-Camp Lejeune	Form and Instruction
1 Health Survey Attachment C survey.doc	Form and Instruction
Attachment D prenotice.docx Attachment D prenotice	IC Document
Attachment E ltr of invitation.docx Attachment E ltr of invitation	IC Document
Attachment F email invite.docx Attachment F email invite	IC Document
Attachment G postcard.docx Attachment G postcard	IC Document
Attachment H email thank you.docx Attachment H email thank you	IC Document
Attachment I reminder.docx Attachment I reminder	IC Document
Attachment J email reminder.docx Attachment J email reminder	IC Document
Attachment K telephone.docx Attachment K telephone	IC Document
Attachment L prenotice reg.docx Attachment L prenotice reg	IC Document
Attachment M invite reg.docx Attachment M invite reg	IC Document
Attachment N consent.doc Attachment N consent	IC Document
Attachment O consent reg.doc Attachment O consent reg	IC Document
Attachment P protocol.docx Attachment P protocol	IC Document
Attachment Q med rec release.doc Attachment Q med rec release	IC Document
Attachment R IRB approval.htm Attachment R IRB approval	IC Document
Attachment S IRB amendment.docx Attachment S IRB amendment	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Health Survey	Attachment C survey.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-19-0001-"Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances"

FR Citation: 57 FR 62812

Number of Respondents: 45,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	45,500	45,500
Annual IC Time Burden (Hours)	34,125	34,125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment D prenotice	Attachment D prenotice.docx	05/10/2010
Attachment E ltr of invitation	Attachment E ltr of invitation.docx	05/10/2010
Attachment F email invite	Attachment F email invite.docx	05/10/2010
Attachment G postcard	Attachment G postcard.docx	05/10/2010
Attachment H email thank you	Attachment H email thank you.docx	05/10/2010
Attachment I reminder	Attachment I reminder.docx	05/10/2010
Attachment J email reminder	Attachment J email reminder.docx	05/10/2010
Attachment K telephone	Attachment K telephone.docx	05/10/2010
Attachment L prenotice reg	Attachment L prenotice reg.docx	05/10/2010
Attachment M invite reg	Attachment M invite reg.docx	05/10/2010
Attachment N consent	Attachment N consent.doc	05/10/2010
Attachment O consent reg	Attachment O consent reg.doc	05/10/2010
Attachment P protocol	Attachment P protocol.docx	05/10/2010
Attachment Q med rec release	Attachment Q med rec release.doc	05/10/2010
Attachment R IRB approval	Attachment R IRB approval.htm	05/10/2010
Attachment S IRB amendment	Attachment S IRB amendment.docx	05/10/2010

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