Information Collection

Initial Medical Exam Form

IC 217788 under ICR 201508-0970-003 · OMB 0970-0466.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

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.