Information Collection

Medical Records Privacy Act Release Form

IC 255165 under ICR 202208-1651-001 · OMB 1651-0144.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3400 Medical Records Privacy Act Release Form	Form and Instruction
3400 Hiring Center Medical Records Privacy Act Release Form CBP Form 3400 Medical Records Release Form.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 339.301 5 CFR 339.305

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 and Instruction	3400	Hiring Center Medical Records Privacy Act Release Form	CBP Form 3400 Medical Records Release Form.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 104

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	208	208
Annual IC Time Burden (Hours)	52	52
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.