Initial Medical Exam Form

Initial Medical Exam Form and Initial Dental Exam Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0466 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Initial Medical Exam Form Form and Instruction
1 Initial Medical Exam Form Initial Medical Exam Form.docx Form and Instruction
1 TB Screening Form Appendix A - Supplemental TB Screening Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Initial Medical Exam Form	Agency IC Tracking Number:	ORR

Is this a Common Form? No		IC Status: New

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	Initial Medical Exam Form	Initial Medical Exam Form.docx		No		Paper Only
Form and Instruction	1	TB Screening Form	Appendix A - Supplemental TB Screening Form.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40,500	40,500
Annual IC Time Burden (Hours)	10,125	10,125
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.