Information Collection

Initial Medical Exam Form

IC 217788 under ICR 202205-0970-003 · OMB 0970-0466.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0466 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Initial Medical Exam Form	Form
Form 1 Initial Medical Exam Form Initial Medical Exam Form	Form
Form 1 Appendix A_Supplemental TB Screening Form Initial Medical Exam Form	Form
1 Initial Medical Exam Form Initial Medical Exam Form_0466_Updated 05062022.docx	Form
1 Initial Medical Exam Form Initial Medical Exam Form_0466_Updated 05062022.docx	Form
1 Appendix A_Supplemental TB Screening Form Supplemental TB Screening Form_Clean.docx	Form
1 Appendix A_Supplemental TB Screening Form Supplemental TB Screening Form_Clean.docx	Form

IC Title:

Initial Medical Exam Form

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Initial Medical Exam Form	Initial Medical Exam Form_0466_Updated 05062022.docx		Yes	Yes	Fillable Fileable
Form	1	Appendix A_Supplemental TB Screening Form	Supplemental TB Screening Form_Clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: ORR Division of Children's Services Records

FR Citation: 81 FR 46682

Number of Respondents: 195

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	52,845	52,845
Annual IC Time Burden (Hours)	31,707	31,707
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.