Information Collection

USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only

IC 205743 under ICR 202406-1105-004 · OMB 1105-0099.

Documents and Forms

Document Name Document Type
Form USM-522P USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only Form and Instruction
USM-522P Physician Evaluation Report for USMS Operational Employe usm522p-20200110.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

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	USM-522P	Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	usm522p-20200110.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: OPM/GOVT-10, Employee Medical File System Records	FR Citation: 65 FR 24732

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	1,608	1,608

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.