Report of Dental Evaluation

Report of Dental Examinitaion

Documents and Forms

Document Name Document Type
Form PC-OMS-1790 Dental Report of Dental Evaluation Form and Instruction
PC-OMS-1790 Dental Report of Dental Evaluation Report_of_Dental_Evaluation.pdf Form and Instruction
Dental-SupportingStatement 2016.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Report of Dental Evaluation	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: Modified

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	PC-OMS-1790 Dental S	Report of Dental Evaluation	Report_of_Dental_Evaluation.pdf		No		Paper Only

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records
Title: Volunteer Applicant and Service Records	FR Citation: 70 FR 1

Number of Respondents: 7,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	7,000	1,400	5,600
Annual IC Time Burden (Hours)	15,750	3,150	12,600
Annual IC Cost Burden (Dollars)	1,260,000	252,000	1,008,000

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Dental-SupportingStatement 2016.docx	01/31/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.