Information Collection

Job Corps Health Questionnaire

IC 12954 under ICR 201703-1205-001 · OMB 1205-0033.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0033 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ETA 653 Job Corps Health Questionnaire	Form and Instruction
ETA 653 Health Questionnaire ETA 653 Job Corps Health Questionnaire_FINAL 5.24.17.docx	Form and Instruction
ETA 653_(track changes) 5.24.17.docx ETA 653 - Job Corps Health Questionnaire (track changes)	IC Document

IC Title:

Job Corps Health Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 670.965

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 and Instruction	ETA 653	Health Questionnaire	ETA 653 Job Corps Health Questionnaire_FINAL 5.24.17.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title: DOL/GOVT-2

FR Citation: 81 FR 25765

Number of Respondents: 66,697

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	66,697	-20,884	87,581
Annual IC Time Burden (Hours)	8,893	1,595	7,298
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ETA 653 - Job Corps Health Questionnaire (track changes)	ETA 653_(track changes) 5.24.17.docx	05/25/2017

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