Information Collection

Personal Medical History

IC 211970 under ICR 201406-0925-002 · OMB 0925-0584.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Personal Medical History	Form and Instruction
1 MHE-Personal Medical History-Eng MHE-Personal Medical History - Eng.pdf	Form and Instruction
MHS-Medical History- Span.pdf MHS-Medical History-Span	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	MHE-Personal Medical History-Eng	MHE-Personal Medical History - Eng.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,878

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	13,878	13,878
Annual IC Time Burden (Hours)	2,313	2,313
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MHS-Medical History-Span	MHS-Medical History- Span.pdf	06/23/2014

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