Information Collection

Veteran Toxic Exposure Screening Tool (PACT Act)

IC 255733 under ICR 202211-2900-011 · OMB 2900-0913.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
TOXIC EXPOSURE SCREENING TOOL_0118_updated Jan 2023.docx	Other-Screening Survey
TOXIC EXPOSURE SCREENING TOOL_0118_updated Jan 2023.docx	Other-Screening Survey
2900-0913 Instrument Passback 2023-02-24_VA edits 030723_CLEAN copy 03102023.docx	Other-Screening Tool

IC Title:

Agency IC Tracking Number:

2900-NEW

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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
Other-Screening Survey			TOXIC EXPOSURE SCREENING TOOL_0118_updated Jan 2023.docx		Yes	Yes	Fillable Fileable
Other-Screening Tool			2900-0913 Instrument Passback 2023-02-24_VA edits 030723_CLEAN copy 03102023.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Patient Medical Record -- VA

FR Citation: 78 FR 17778

Number of Respondents: 1,660,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,660,000	1,660,000
Annual IC Time Burden (Hours)	138,333	138,333
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.