Information Collection

Supplemental Medical History Questionnaire (PFPA Form 6040)

IC 236253 under ICR 201905-0704-007 · OMB 0704-0588.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0588 can be found here:

Documents and Forms

Document Name Document Type
Form PFPA Form 6040 Supplemental Medical History Questionnaire (PFPA Form 6040) Form and Instruction
PFPA Form 6040 Supplemental Medical History Questionnaire PFPA 6040 Supplemetal History Questionnaire2.PDF Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Supplemental Medical History Questionnaire (PFPA Form 6040)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	PFPA Form 6040	Supplemental Medical History Questionnaire	PFPA 6040 Supplemetal History Questionnaire2.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: 240	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	1,920	1,920

Documents for IC

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.