Injury Questionnaire

Report of Medical History/Examination

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form PHS-7055 Injury Questionnaire Form
PHS-7055 Injury PHS-7055-Injury Questionnaire Form

Information Collection (IC) Details

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:

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 %

	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

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.