Information Collection

Report of Dental Evaluation

IC 198187 under ICR 201610-0420-004 · OMB 0420-0546.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0420-0546 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form PC-OMS-1790 Dental Report of Dental Evaluation	Form and Instruction
PC-OMS-1790 Dental Report of Dental Evaluation Report_of_Dental_Evaluation.pdf	Form and Instruction
Dental-SupportingStatement 2016.docx Supporting Statement	IC Document

IC Title:

Report of Dental Evaluation

Agency IC Tracking Number:

Is this a Common Form? Yes

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 and Instruction	PC-OMS-1790 Dental S	Report of Dental Evaluation	Report_of_Dental_Evaluation.pdf		No		Paper Only

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records

Title: Volunteer Applicant and Service Records

FR Citation: 70 FR 1

Number of Respondents: 5,600

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,600	200	5,400
Annual IC Time Burden (Hours)	12,600	8,550	4,050
Annual IC Cost Burden (Dollars)	1,008,000	144,000	864,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	Dental-SupportingStatement 2016.docx	01/31/2017

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