Family Member Medical Summary: Medical Providers

Exceptional Family Member Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0411 can be found here:

Documents and Forms

Document Name Document Type
Form DD 2792 Family Member Medical Summary: Medical Providers Form and Instruction
DD 2792 Family Member Medical Summary 0704-0411_DD2792 20200504 DRAFT.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Family Member Medical Summary: Medical Providers	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	DD 2792	Family Member Medical Summary	0704-0411_DD2792 20200504 DRAFT.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: 11,166	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 30 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11,166	11,166
Annual IC Time Burden (Hours)	4,653	4,653
Annual IC Cost Burden (Dollars)	468,972	468,972

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.