Health Services Questionnaire

NOAA Teacher-At-Sea Program

Documents and Forms

Document Name Document Type
Form NOAA Form 57-10-01 Health Services Questionnaire Form and Instruction
NOAA Form 57-10-01 NOAA Health Services Questionnaire with Tuberculosis Scr NOAA Health Services Questionnaire.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Health Services Questionnaire	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 and Instruction	NOAA Form 57-10-01	NOAA Health Services Questionnaire with Tuberculosis Screening Document	NOAA Health Services Questionnaire.pdf		Yes	Yes	Fillable Printable

Line of Business: Natural Resources

Subfunction: Conservation, Marine and Land Management

Privacy Act System of Records
Title: COMMERCE/NOAA-22	FR Citation: 81 FR 10576

Number of Respondents: 45	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	45	0	45
Annual IC Time Burden (Hours)	34	0	34
Annual IC Cost Burden (Dollars)	0	-95	95

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.