Mammogram 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⚠️ Notice: This information collection may be referencing outdated material.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-355-2 Mammogram Form Form and Instruction
PC-355-2 Mammogram Waiver Form Mammogram_Waiver.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Mammogram Form	Agency IC Tracking Number:	PC-355-2

Is this a Common Form? No		IC Status: Modified

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-355-2	Mammogram Waiver Form	Mammogram_Waiver.docx		Yes	No	Fillable Printable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records
Title: Mammogram Waiver Form	FR Citation: 70 FR 1

Number of Respondents: 148	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	148	-76	224
Annual IC Time Burden (Hours)	259	-133	392
Annual IC Cost Burden (Dollars)	0	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.