Information Collection

USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only

IC 205743 under ICR 201712-1105-002 · OMB 1105-0099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1105-0099 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form USM-522P USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	Form and Instruction
USM-522P Physician Evaluation Report for USMS Operational Employe usm522p.pdf	Form and Instruction

IC Title:

USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only

Agency IC Tracking Number:

USMS-2013-1-522P

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

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 and Instruction	USM-522P	Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	usm522p.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: OPM/GOVT-10, Employee Medical File System Records

FR Citation: 65 FR 24732

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	1,608	1,608

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.