Information Collection

Health Assessment Form

IC 229902 under ICR 202205-0970-004 · OMB 0970-0509.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0509 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Health Assessment Form	Form
1 Health Assessment Form Health Assessment Form_0509_Updated 05092022.docx	Form
1 Health Assessment Form Health Assessment Form_0509_Updated 05092022.docx	Form

IC Title:

Health Assessment 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	Health Assessment Form	Health Assessment Form_0509_Updated 05092022.docx		Yes	Yes	Fillable Printable

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	105,690	105,690
Annual IC Time Burden (Hours)	38,048	38,048
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.