Initial Medical Exam Form

Initial Medical Exam Form and Dental Exam Form

OMB: 0970-0466

IC ID: 217788

Information Collection (IC) Details

View Information Collection (IC)

Initial Medical Exam Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

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

Community and Social Services Social Services

ORR Division of Children's Services Records  81 FR 46682

195 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 52,845 0 0 0 0 52,845
Annual IC Time Burden (Hours) 31,707 0 0 0 0 31,707
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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