Information Collection

Child and Youth Program Forms

IC 234105 under ICR 202202-0704-005 · OMB 0704-0582.

Documents and Forms

Document Name Document Type
Form DLA Form 1849 Child and Youth Program Forms Form
DLA Form 1849 Child and Youth Program (CYP) Medication Consent and Adm DL1849.pdf Form
DLA Form 1849 Child and Youth Program (CYP) Medication Consent and Adm DL1849.pdf Form
DLA Form 1849-1 DLA Child and Youth Program (CYP) Parental Consent for F DL1849-1.pdf Form
DLA Form 1849-1 DLA Child and Youth Program (CYP) Parental Consent for F DL1849-1.pdf Form
DLA Form 1849-2 DLA CYP Insect Repellent Use Consent DL1849-2.pdf Form
DLA Form 1849-2 DLA CYP Insect Repellent Use Consent DL1849-2.pdf Form
DLA Form 1849-3 DLA CYP Basic Care Item Consent to Apply DL1849-3.pdf Form
DLA Form 1849-3 DLA CYP Basic Care Item Consent to Apply DL1849-3.pdf Form
DLA Form 1849-4 DLA CYP Child Illness/Injury Readmission Record DL1849-4.pdf Form
DLA Form 1849-4 DLA CYP Child Illness/Injury Readmission Record DL1849-4.pdf Form
DLA Form 1855 DLA Child and Youth Program Health/Developmental Screeni DL1855.pdf Form
DLA Form 1855 DLA Child and Youth Program Health/Developmental Screeni DL1855.pdf Form
DLA Form 1855-1 DLA Child and Youth Program Health Assessment for Enroll DL1855-1.pdf Form
DLA Form 1855-1 DLA Child and Youth Program Health Assessment for Enroll DL1855-1.pdf Form
DLA Form 1855-1A DLA Child and Youth Program Respiratory Medical Action P DL1855-1A.pdf Form
DLA Form 1855-1A DLA Child and Youth Program Respiratory Medical Action P DL1855-1A.pdf Form
DLA Form 1855-1B DLA Child and Youth Program Special Diet Statement DL1855-1B.pdf Form
DLA Form 1855-1B DLA Child and Youth Program Special Diet Statement DL1855-1B.pdf Form
DLA Form 1855-1C DLA Child and Youth Program Epilepsy/Seizure Medical Act DL1855-1C.pdf Form
DLA Form 1855-1C DLA Child and Youth Program Epilepsy/Seizure Medical Act DL1855-1C.pdf Form
DLA Form 1855-1D P DLA CYP Diabetes Daily Medical Action Plan DL1855-1D Part I.pdf Form
DLA Form 1855-1D P DLA CYP Diabetes Daily Medical Action Plan DL1855-1D Part I.pdf Form
DLA Form 1855-1D P DLA CYP Diabetes Emergency Medical Action Plan DL1855-1D Part 2.pdf Form
DLA Form 1855-1D P DLA CYP Diabetes Emergency Medical Action Plan DL1855-1D Part 2.pdf Form
DLA Form 1855-1D P DLA CYP Diabetes Weekly Food and Carbohydrate Log DL1855-1D Part III.pdf Form
DLA Form 1855-1D P DLA CYP Diabetes Weekly Food and Carbohydrate Log DL1855-1D Part III.pdf Form
DLA Form 1855-1D P DLA Child and Youth Program Blood Glucose and Ketone Mon DL1855-1D Part 4.pdf Form
DLA Form 1855-1D P DLA Child and Youth Program Blood Glucose and Ketone Mon DL1855-1D Part 4.pdf Form
DLA Form 1855-1E DLA Child and Youth Program (CYP) Allergy Medical Action DL1855-1E.pdf Form
DLA Form 1855-1E DLA Child and Youth Program (CYP) Allergy Medical Action DL1855-1E.pdf Form
DLA Form 1855-1F DLA Child and Youth Program Consent to Perform Caregivin DL1855-1F- OMB Review Final.pdf Form
DLA Form 1855-1F DLA Child and Youth Program Consent to Perform Caregivin DL1855-1F- OMB Review Final.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Child and Youth Program Forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DLA Form 1849	Child and Youth Program (CYP) Medication Consent and Administration Log	DL1849.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1849-1	DLA Child and Youth Program (CYP) Parental Consent for Field Trip	DL1849-1.pdf	Yes	Yes	Fillable Fileable
Form	DLA Form 1849-2	DLA CYP Insect Repellent Use Consent	DL1849-2.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1849-3	DLA CYP Basic Care Item Consent to Apply	DL1849-3.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1849-4	DLA CYP Child Illness/Injury Readmission Record	DL1849-4.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855	DLA Child and Youth Program Health/Developmental Screening	DL1855.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855-1	DLA Child and Youth Program Health Assessment for Enrollment and Renewal	DL1855-1.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855-1A	DLA Child and Youth Program Respiratory Medical Action Plan	DL1855-1A.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855-1B	DLA Child and Youth Program Special Diet Statement	DL1855-1B.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855-1C	DLA Child and Youth Program Epilepsy/Seizure Medical Action Plan	DL1855-1C.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855-1D Part 1	DLA CYP Diabetes Daily Medical Action Plan	DL1855-1D Part I.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855-1D Part II	DLA CYP Diabetes Emergency Medical Action Plan	DL1855-1D Part 2.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855-1D Part III	DLA CYP Diabetes Weekly Food and Carbohydrate Log	DL1855-1D Part III.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855-1D Part IV	DLA Child and Youth Program Blood Glucose and Ketone Monitoring Log	DL1855-1D Part 4.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855-1E	DLA Child and Youth Program (CYP) Allergy Medical Action Plan	DL1855-1E.pdf	Yes	Yes	Fillable Fileable Signable
Form	DLA Form 1855-1F	DLA Child and Youth Program Consent to Perform Caregiving Health Practices and Authorization for Disclosure of Health Information	DL1855-1F- OMB Review Final.pdf	Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 828	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,055	10,399	1,656
Annual IC Time Burden (Hours)	1,005	873	132
Annual IC Cost Burden (Dollars)	20,252	17,337	2,915

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.