Injury Questionnaire

Report of Medical History/Examination

OMB: 0990-0324

IC ID: 182398

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Injury Questionnaire
 
No Unchanged
 
Required to Obtain or Retain Benefits
 

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

General Government Central Records & Statistical Mgt

PHS Commissioned Corps Medical Records  63 FR 68596

2,800 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,800 0 2,800 0 0 0
Annual IC Time Burden (Hours) 327 0 327 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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