Information Collection

Former POW Medical History

IC 28634 under ICR 201504-2900-009 · OMB 2900-0427.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-0048 Former POW Medical History	Form
10-0048 Former POW Medical History FPOW 10-0048-fill2.pdf vaww.va.gov/vaforms/medical/pdf/vha-10-0048-fill.pdf	Form

IC Title:

Agency IC Tracking Number:

2900-0427

Is this a Common Form? No

IC Status: Modified

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	10-0048	Former POW Medical History	FPOW 10-0048-fill2.pdf	http://vaww.va.gov/vaforms/medical/pdf/vha-10-0048-fill.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 75

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	113	113
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.