Information Collection

Environmental Hazards Registry (EHR) Worksheet for Veterans

IC 236782 under ICR 201907-2900-001 · OMB 2900-0893.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10176 Environmental Hazards Registry (EHR) Worksheet for Veterans	Form
10-10176 Environmental Hazards Registry (EHR) Worksheet for Veter VA Form 10-10176_revised 2020.pdf	Form

IC Title:

Agency IC Tracking Number:

2900-NEW

Is this a Common Form? No

IC Status: New

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	10-10176	Environmental Hazards Registry (EHR) Worksheet for Veterans	VA Form 10-10176_revised 2020.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	20,000	20,000
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.