Information Collection

Report of Medical Examination

IC 182394 under ICR 202006-0990-002 · OMB 0990-0324.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form PHS-6379 Report of Medical Examination	Form
PHS-6379 Medical History Record phs-6379.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

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	PHS-6379	Medical History Record	phs-6379.pdf		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title: PHS Commissioned Corps Medical Records

FR Citation: 63 FR 68596

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-4,000	4,000
Annual IC Time Burden (Hours)	-2,000	2,000
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.