Information Collection

Injury Questionnaire

IC 182398 under ICR 201612-0990-001 · OMB 0990-0324.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0324 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form PHS-7055 Injury Questionnaire	Form
PHS-7055 Injury PHS-7055-Injury Questionnaire	Form

IC Title:

Injury Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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	PHS-7055	Injury	PHS-7055-Injury Questionnaire		No	No	Printable Only

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title: PHS Commissioned Corps Medical Records

FR Citation: 63 FR 68596

Number of Respondents: 2,800

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
Annual Number of Responses for this IC	2,800	2,800
Annual IC Time Burden (Hours)	327	327
Annual IC Cost Burden (Dollars)	0	0

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.