Information Collection

Professional Qualifications Medical/Peer Reviewers

IC 5569 under ICR 202102-0720-001 · OMB 0720-0005.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0005 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DHA 780 Professional Qualifications Medical/Peer Reviewers	Form
DHA 780 Professional Qualifications Medical Peer Reviewers DHA780_ProfQualMedPeerReview_20200817_DRAFT.pdf	Form
DHA 780 Professional Qualifications Medical Peer Reviewers DHA780_ProfQualMedPeerReview_20200817_DRAFT.pdf	Form
Privacy Act Review - No PAS Needed.docx Privacy Act Review - PAS Not Required	IC Document
Privacy Act Review - No PAS Needed.docx Privacy Act Review - PAS Not Required	IC Document
Instructions for DHA 780.pdf Instructions	IC Document
Instructions for DHA 780.pdf Instructions	IC Document

IC Title:

Professional Qualifications Medical/Peer Reviewers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	DHA 780	Professional Qualifications Medical Peer Reviewers	DHA780_ProfQualMedPeerReview_20200817_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: 60

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60	0	60
Annual IC Time Burden (Hours)	20	0	20
Annual IC Cost Burden (Dollars)	2,000	200	1,800

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Privacy Act Review - PAS Not Required	Privacy Act Review - No PAS Needed.docx	02/09/2021
Instructions	Instructions for DHA 780.pdf	02/09/2021

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