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Environmental Hazards Registry (EHR) Worksheet for Veterans
Environmental Hazards Registry (EHR) Worksheet (VA Form 10-10176)
OMB: 2900-0893
IC ID: 236782
OMB.report
VA
OMB 2900-0893
ICR 201907-2900-001
IC 236782
( )
Documents and Forms
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
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Environmental Hazards Registry (EHR) Worksheet for Veterans
Agency IC Tracking Number:
2900-NEW
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
10-10176
Environmental Hazards Registry (EHR) Worksheet for Veterans
VA Form 10-10176_revised 2020.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
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 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
20,000
0
20,000
0
0
0
Annual IC Time Burden (Hours)
20,000
0
20,000
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
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.
