Information Collection

Disease Diagnosis Form

IC 201685 under ICR 201203-0420-001 · OMB 0420-0550.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0420-0550 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form PC-262-5 Disease Diagnosis Form	Form and Instruction
PC-262-5 Disease Diagnosis Evaluation Form Disease Diagnosis Evaluation Form PC-262-5.docx	Form and Instruction

IC Title:

Disease Diagnosis Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	PC-262-5	Disease Diagnosis Evaluation Form	Disease Diagnosis Evaluation Form PC-262-5.docx		Yes	Yes	Fillable Printable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records

Title: Volunteer Applicant and Service Records

FR Citation: 70 FR 1

Number of Respondents: 800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	1,400	1,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.