Information Collection

Health Record

IC 231570 under ICR 202107-0693-003 · OMB 0693-0080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0693-0080 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NIST-986 Health Record	Form
NIST-986 Health Record NIST-986 Health Record_4-28-2021FormsMngmt.docx	Form
NIST-986 Health Record NIST-986 Health Record_4-28-2021FormsMngmt.docx	Form

IC Title:

Health Record

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	NIST-986	Health Record	NIST-986 Health Record_4-28-2021FormsMngmt.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: COMMERCE/DEPT-18: Employees Personnel Files Not Covered by Notices of Other Agencies

FR Citation: 72 FR 6200

Number of Respondents: 333

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	333	333
Annual IC Time Burden (Hours)	56	56
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.