Information Collection

Health and Wellness

IC 272405 under ICR 202411-1205-003 · OMB 1205-0219.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ETA 9222 Health and Wellness	Form
Form ETA 9222 Health and Wellness Center Annual Program Description Health and Wellness	Form
Form ETA 9212 Alcohol Testing Report Health and Wellness	Form
Form ETA 9214 Social Intake Form Health and Wellness	Form
Form ETA 9216 Health History Form Health and Wellness	Form
Form ETA 9217 Lab Testing Information Sheet Health and Wellness	Form
Form ETA 9213 Immunization Record Health and Wellness	Form
Form ETA 9215 Physical Examination Form Health and Wellness	Form
ETA 9222 Health and Wellness Center Annual Program Description ETA 9222 Health and Wellness Center Annual Program Description APD.docx	Form
ETA 9222 Health and Wellness Center Annual Program Description ETA 9222 Health and Wellness Center Annual Program Description APD.docx	Form
ETA 9212 Alcohol Testing Report ETA 9212 Alcohol Testing Report.docx	Form
ETA 9212 Alcohol Testing Report ETA 9212 Alcohol Testing Report.docx	Form
ETA 9214 Social Intake Form ETA 9214 Social Intake Form_EO 14168 Changes.docx	Form
ETA 9214 Social Intake Form ETA 9214 Social Intake Form_EO 14168 Changes.docx	Form
ETA 9216 Health History Form ETA 9216 Health History Form_EO 14168 Changes.docx	Form
ETA 9216 Health History Form ETA 9216 Health History Form_EO 14168 Changes.docx	Form
ETA 9217 Lab Testing Information Sheet ETA 9217 Laboratory Testing Information Sheet.docx	Form
ETA 9217 Lab Testing Information Sheet ETA 9217 Laboratory Testing Information Sheet.docx	Form
ETA 9213 Immunization Record ETA 9213 Immunization Record_Updated.docx	Form
ETA 9213 Immunization Record ETA 9213 Immunization Record_Updated.docx	Form
ETA 9215 Physical Examination Form ETA 9215 Physical Examination Form_Updated_EO 14168 Changes.docx	Form
ETA 9215 Physical Examination Form ETA 9215 Physical Examination Form_Updated_EO 14168 Changes.docx	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Health and Wellness

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 686

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	ETA 9222	Yes	Yes	Fillable Fileable
Form	ETA 9212	Yes	Yes	Fillable Fileable
Form	ETA 9214	Yes	Yes	Fillable Fileable
Form	ETA 9216	Yes	Yes	Fillable Fileable
Form	ETA 9217	Yes	Yes	Fillable Fileable
Form	ETA 9213	Yes	Yes	Fillable Fileable
Form	ETA 9215	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title: DOL/GOVT-2. (Job Corps Student Records)

FR Citation: 67 FR 16815

Number of Respondents: 847

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	179,105	179,105
Annual IC Time Burden (Hours)	89,458	89,458
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.

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