DI-4015, Youth Conservation Corps Medical History Form

Youth Conservation Corps Application and Medical History Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1093-0010 can be found here:

Documents and Forms

Document Name Document Type
Form DI-4015 DI-4015, Youth Conservation Corps Medical History Form Form and Instruction
DI-4015 Medical History Form DI-4015 YCC Medical History Form updated 10282020.docx Form and Instruction

Information Collection (IC) Details

IC Title:	DI-4015, Youth Conservation Corps Medical History Form	Agency IC Tracking Number:

Is this a Common Form? Yes		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	DI-4015	Medical History Form	DI-4015 YCC Medical History Form updated 10282020.docx		Yes	Yes	Fillable Fileable

Line of Business: Natural Resources

Subfunction: Conservation, Marine and Land Management

Privacy Act System of Records
Title: INTERIOR/OS-25, YCC Enrollee Records	FR Citation: 56 FR 41700

Number of Respondents: 2,810	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	2,810	2,810
Annual IC Time Burden (Hours)	656	656
Annual IC Cost Burden (Dollars)	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.