Information Collection Request

Initial Medical Exam Form and Dental Exam Form

ICR 202205-0970-003 · OMB 0970-0466 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 1 Dental Exam Form Form Unchanged Available
Form 1 Dental Exam Form Form Unchanged Repair queued
Form 1 Appendix A_Supplemental TB Screening Form Form Modified Available
Form 1 Initial Medical Exam Form Form Modified Available
Form 1 Initial Medical Exam Form Form Modified Repair queued
NonSub Change Request_0466.docx Justification for No Material/Nonsubstantive Change Uploaded 2022-05-09 Repair queued
SUPSTAT_HHS OMB 0970-0466_Final.docx Supporting Statement A Uploaded 2020-09-28 Repair queued
Attachment A - Flores Agreement.doc Supplementary Document Uploaded 2015-08-05 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
217789 Dental Exam Form Form UnchangedDental Exam Form
217789 Dental Exam Form Form Unchanged
217788 Initial Medical Exam Form Form ModifiedAppendix A_Supplemental TB Screening Form
217788 Initial Medical Exam Form Form ModifiedInitial Medical Exam Form
217788 Initial Medical Exam Form Form Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
12/31/2023 12/31/2023 12/31/2023
61,815 0 61,815
33,950 0 33,950
0 0 0





Reginfo record details
2
table that charts list of burden
IC Title Form No. Form Name
Dental Exam Form 1
Initial Medical Exam Form 1, 1 ,  

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 61,815 61,815 0 0 0 0
Annual Time Burden (Hours) 33,950 33,950 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No