Information Collection

JSC Form 1830 – Report of Medical Examination

IC 234962 under ICR 202306-2700-001 · OMB 2700-0170.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2700-0170 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1830 Report of Medical Examination JSC Form 1830 – Report of Medical Examination	Form
2700-0170 2023 CX12-UWI0001.docx	Other-Guest Diving Procedure
1830 Report of Medical Examination 2700-0170 2023 JF1830.docx	Form
1830 Report of Medical Examination 2700-0170 2023 JF1830.docx	Form

IC Title:

JSC Form 1830 â Report of Medical Examination

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	1830				Yes	Yes	Fillable Fileable

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title: NASA 10HIMS - Health Information Management System

FR Citation: 86 FR 71097

Number of Respondents: 30

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 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	45	45
Annual IC Cost Burden (Dollars)	2,250	2,250

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.

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