Information Collection

Health Services Questionnaire

IC 207090 under ICR 202302-0648-002 · OMB 0648-0283.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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 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 %

table that charts list of burden
	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

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.