Functional Abilities Evaluation 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⚠️ Notice: This information collection may be referencing outdated material.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-262-15 Functional Abilities Evaluation Form Form and Instruction
PC-262-15 Functional Abilities Evaluation Form Functional_Abilities_Evaluation.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Functional Abilities Evaluation Form	Agency IC Tracking Number:	PC-262-15

Is this a Common Form? No		IC Status: New

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-262-15	Functional Abilities Evaluation Form	Functional_Abilities_Evaluation.docx		Yes	No	Fillable Printable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	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
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	225	225
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.