OMB83-C_followuptoNAForms13036&others

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/Subagency

National Archives and Records Administration

OMB Control Number

3 0 9 5 – 0 0 3 9

Enter only items that change

Current record New record

Agency form number(s) NA Form 13177
Annual reporting and recordkeeping hour burden Number of respondents Total annual respondents Percent of these responses collected electronically Total annual hours Difference Explanation of difference Program change Adjustment
	     	     
	     	     
	100%	     %
	     	     
		     
		     
		           
Annual reporting and recordkeeping cost burden (in thousands of dollars) Total annualized Capital/Startup costs Total annual costs (O&M) Total annualized cost requested Difference Explanation of difference Program change Adjustment
	     	     
	     	     
	     	     
		     
		           

Other changes**Note: This form would be a follow-up NA Form 13036, Authorization for Release of Military Medical Patient Records; NA Form 13042, Request for Information Needed to Locate Medical Records; NA Form 13055, Request for Information Needed to Reconstruct Medical Data; and NA Form 13075, Questionnaire about Military Service, allowing customers to receive a status update for existing requests.

Signature of Senior Official or Designee:

Executive for Information Services/CIO

Date:

For OIRA Use

** This form cannot be used to extend an expiration date.

OMB FORM 83–C, 10/95