Information Collection

Professional Qualifications Medical/Peer Reviewers

IC 5569 under ICR 201701-0720-001 · OMB 0720-0005.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0005 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DHA 780 Professional Qualifications Medical/Peer Reviewers	Form
Instructions for DHA 780.pdf	Instruction
Privacy Act Review - No PAS Needed.doc	Other-Privacy Act Review - No PAS re
DHA 780 DHA 780 dha780_20160323.pdf	Form

IC Title:

Professional Qualifications Medical/Peer Reviewers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DHA 780	DHA 780	dha780_20160323.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			Instructions for DHA 780.pdf	Yes	No	Fillable Fileable
Other-Privacy Act Review - No PAS required			Privacy Act Review - No PAS Needed.doc	No		Paper Only

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	60	0	60
Annual IC Time Burden (Hours)	20	5	15
Annual IC Cost Burden (Dollars)	1,800	1,050	750

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.