Information Collection

DD Form X678 Series

IC 223831 under ICR 201610-0704-001 · OMB 0704-0560.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0560 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD X678-4 TEST DD Form X678 Series	Form and Instruction
DD X678 TEST Screening Verification DDX678 TEST.PDF	Form and Instruction
DD X678-1 TEST Medical and Educational Information DDX678-1 TEST.PDF	Form and Instruction
DD X678-2 TEST Dental Health Information DDX678-2 TEST.PDF	Form and Instruction
DD X678-3 TEST Patient Care Review DDX678-3 TEST.PDF	Form and Instruction
DD X678-4 TEST Administrative Review Checklist DDX678-4 TEST.pdf	Form and Instruction

IC Title:

DD Form X678 Series

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	DD X678-4 TEST	Administrative Review Checklist	DDX678-4 TEST.pdf	No	Paper Only
Form and Instruction	DD X678 TEST	Screening Verification	DDX678 TEST.PDF	No	Paper Only
Form and Instruction	DD X678-1 TEST	Medical and Educational Information	DDX678-1 TEST.PDF	No	Paper Only
Form and Instruction	DD X678-2 TEST	Dental Health Information	DDX678-2 TEST.PDF	No	Paper Only
Form and Instruction	DD X678-3 TEST	Patient Care Review	DDX678-3 TEST.PDF	No	Paper Only

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17,943

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

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	17,943	17,943
Annual IC Time Burden (Hours)	4,617	4,617
Annual IC Cost Burden (Dollars)	177,030	177,030

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.