Information Collection

DLA Form 1855-1F

IC 234117 under ICR 201811-0704-003 · OMB 0704-0582.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0582 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DLA Form 1855-1F DLA Form 1855-1F	Form
DLA Form 1855-1F DLA Child and Youth Program Consent to Perform Caregivin DL1855-1F- OMB Review Final.pdf	Form

IC Title:

DLA Form 1855-1F

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	DLA Form 1855-1F	DLA Child and Youth Program Consent to Perform Caregiving Health Practices and Authorization for Disclosure of Health Information	DL1855-1F- OMB Review Final.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 75

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	132	132

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.