Health Survey

Morbidity Study of Former Marines, Dependents, and Employees Potentially Exposed to Contaminated Drinking Water at USMC Base Camp Lejeune

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0042 can be found here:

Documents and Forms

Document Name Document Type
Health Survey Form
Health Survey Attachment C survey.doc Form
Health Survey Attachment C survey 2011_10 clean.docx Form

Information Collection (IC) Details

IC Title:	Health Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Health Survey	Attachment C survey.doc		Yes	Yes	Fillable Fileable
Form	None	Health Survey	Attachment C survey 2011_10 clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 47,601	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	47,601	47,601
Annual IC Time Burden (Hours)	35,701	35,701
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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