Health Assessment Form

Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.