Information Collection

DI-4015, Youth Conservation Corps Medical History Form

IC 242577 under ICR 202001-1093-001 · OMB 1093-0010.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.