Information Collection

JSC Form 1830 – Report of Medical Examination

IC 234962 under ICR 201902-2700-001 · OMB 2700-0170.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2700-0170 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form JSC Form 1830 JSC Form 1830 – Report of Medical Examination	Form
CX12-UWI0001.docx	Instruction
JSC Form 1830 Report of Medical Examination JF1830v12.docx kryptiq.jsc.nasa.gov/portal/default.aspx	Form
nasa_10hims_SORN.docx NASA 10HIMS SORN	IC Document

IC Title:

JSC Form 1830 â Report of Medical Examination

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	JSC Form 1830	Report of Medical Examination	JF1830v12.docx	https://kryptiq.jsc.nasa.gov/portal/default.aspx	Yes	Yes	Fillable Fileable
Instruction			CX12-UWI0001.docx		Yes	Yes	Printable Only

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title: NASA 10HIMS - Health Information Management System

FR Citation: 80 FR 214

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	45	45
Annual IC Cost Burden (Dollars)	2,250	2,250

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NASA 10HIMS SORN	nasa_10hims_SORN.docx	02/14/2019

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