Information Collection

Agent Orange Registry Code Sheet

IC 28576 under ICR 201609-2900-003 · OMB 2900-0376.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-9009 Agent Orange Registry Code Sheet	Form
VA Form 10-9009 Agent Orange Registry Code Sheet VA Form 10-9009.pdf vaww.registries.aac.va.gov	Form

IC Title:

Agency IC Tracking Number:

2900-0376

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	VA Form 10-9009	Agent Orange Registry Code Sheet	VA Form 10-9009.pdf	http://vaww.registries.aac.va.gov	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 24VA10P2, Patient Medical Record â VA

FR Citation: 77 FR 65938

Number of Respondents: 20,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	6,667	6,667
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.