Disease Diagnosis Form

Individual Specific Medical Evaluation Forms (15)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0420-0550 can be found here:

Documents and Forms

Document Name Document Type
Form PC-262-5 Disease Diagnosis Form Form and Instruction
PC-262-5 Disease Diagnosis Evaluation Form Disease Diagnosis Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Disease Diagnosis Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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 and Instruction	PC-262-5	Disease Diagnosis Evaluation Form	Disease Diagnosis Form.pdf		Yes	Yes	Fillable Printable

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: 800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-800	800
Annual IC Time Burden (Hours)	-1,400	1,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.