Information Collection

Medical Release and Healthcare Source Forms

IC 221994 under ICR 201802-0920-004 · OMB 0920-1162.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1162 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Medical Release and Healthcare Source Forms	Form
Medical Release and Healthcare Source Form - English Attachment 7a. Medical Release and Healthcare Source Forms English 2016 06 10.docx	Form
Medical Release and Healthcare Source Form - Spanish Attachment 7b. Medical Release and Healthcare Source Forms Spanish.docx	Form

IC Title:

Medical Release and Healthcare Source Forms

Agency IC Tracking Number:

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	none	Medical Release and Healthcare Source Form - English	Attachment 7a. Medical Release and Healthcare Source Forms English 2016 06 10.docx		No		Paper Only
Form	none	Medical Release and Healthcare Source Form - Spanish	Attachment 7b. Medical Release and Healthcare Source Forms Spanish.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 334

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	334	334
Annual IC Time Burden (Hours)	28	28
Annual IC Cost Burden (Dollars)	0	0

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.