Long Term Health Outcome Survey

Peace Corps Volunteers Long Term Health Outcomes Survey

Documents and Forms

Document Name Document Type
Form 2155 Long Term Health Outcome Survey Form
2155 RPCV Long Term Health Outcomes Survey LTC form_Survey v2.pdf Form
Long Term Health Survey_Supporting Statement_v2.docx Long Term Health Survey_Supporting Statement_v2 IC Document
_Lonh Term Healh Survey_Protocol.docx _Lonh Term Healh Survey_Protocol IC Document

Information Collection (IC) Details

IC Title:	Long Term Health Outcome Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2155	RPCV Long Term Health Outcomes Survey	LTC form_Survey v2.pdf		Yes	Yes	Fillable Fileable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11,196	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11,196	11,196
Annual IC Time Burden (Hours)	2,799	2,799
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Long Term Health Survey_Supporting Statement_v2	Long Term Health Survey_Supporting Statement_v2.docx	05/25/2016
_Lonh Term Healh Survey_Protocol	_Lonh Term Healh Survey_Protocol.docx	05/25/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.