Information Collection

Mammogram Form

IC 201714 under ICR 201808-0420-004 · OMB 0420-0550.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form PC-355-2 Mammogram Waiver Form Mammogram Form	Form and Instruction
PC-355-2 Mammogram Waiver Form Mammogram_Waiver.docx	Form and Instruction

IC Title:

Mammogram Form

Agency IC Tracking Number:

PC-355-2

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	PC-355-2				Yes	No	Fillable Printable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records

Title: Mammogram Waiver Form

FR Citation: 70 FR 1

Number of Respondents: 148

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	148	148
Annual IC Time Burden (Hours)	259	259
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.

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