Information Collection

Form 10-2201E, "Physician Consent Form"

IC 222239 under ICR 201606-1024-003 · OMB 1024-0245.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1024-0245 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 10-2201E Form 10-2201E, "Physician Consent Form"	Form and Instruction
Form 10-2201E Physician Consent Form 1024-0245 Form 10-2201E Physician Consent Form 07202017.docx	Form and Instruction

IC Title:

Form 10-2201E, "Physician Consent Form"

Agency IC Tracking Number:

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	Form 10-2201E	Physician Consent Form	1024-0245 Form 10-2201E Physician Consent Form 07202017.docx		Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title: OPM/GOVT-5 -Recruiting, Examining, and Placement Records

FR Citation: 71 FR 35351

Number of Respondents: 2,500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	2,500	2,500
Annual IC Time Burden (Hours)	625	625
Annual IC Cost Burden (Dollars)	250	250

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.