Health Screening Questionnaire-Forest Service

Health Screening Questionnaire

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0596-0164 can be found here:

Documents and Forms

Document Name Document Type
Form FS-5100-31 Health Screening Questionnaire-Forest Service Form
FS-5100-31 Health Screening Questionnaire FS-5100-31 v8-2009.doc www.fs.fed.us/fire/safety/wct/wct_index.html Form
FS 5100-30 Work Capacity Test - Informed Consent 0596-0164 FS_5100_30 v07-2015 final_508.docx www.fs.fed.us/fire/safety/wct/wct_index.html Form

Information Collection (IC) Details

IC Title:	Health Screening Questionnaire-Forest Service	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	FS-5100-31	Health Screening Questionnaire	FS-5100-31 v8-2009.doc	http://www.fs.fed.us/fire/safety/wct/wct_index.html	Yes	No	Fillable Printable
Form	FS 5100-30	Work Capacity Test - Informed Consent	0596-0164 FS_5100_30 v07-2015 final_508.docx	http://www.fs.fed.us/fire/safety/wct/wct_index.html	Yes	Yes	Fillable Printable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,630	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 40 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25,260	25,260
Annual IC Time Burden (Hours)	2,097	2,097
Annual IC Cost Burden (Dollars)	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.