Information Collection

HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability

IC 6427 under ICR 201306-0915-004 · OMB 0915-0204.

Documents and Forms

Document Name Document Type
Form 1 HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability Form and Instruction
1 HEAL Form 539-Disability form539.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	HEAL Form 539-Disability	form539.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	90	-138	228
Annual IC Time Burden (Hours)	23	-34	57
Annual IC Cost Burden (Dollars)	0	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.