Information Collection

Medical Assessment Form - Reporting Time for Pediatricians, General

IC 217788 under ICR 202502-0970-013 · OMB 0970-0466.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Medical Assessment Form - Reporting Time for Pediatricians, General	Form
Form 1 Medical Assessment Form Medical Assessment Form - Reporting Time for Pediatricians, General	Form
1 Medical Assessment Form ORR Medical Assessment Form_0970-0466_clean.docx	Form
1 Medical Assessment Form ORR Medical Assessment Form_0970-0466_clean.docx	Form
Attachment B_Medical Assessment Form Instructional Letter for Medical Providers.docx Attachment B - Medical Assessment Form Instructional Letter for Medical Providers	IC Document
Attachment B_Medical Assessment Form Instructional Letter for Medical Providers.docx Attachment B - Medical Assessment Form Instructional Letter for Medical Providers	IC Document

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	1				Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: ORR Division of Children's Services Records

FR Citation: 81 FR 46682

Number of Respondents: 300

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	Previously Approved
Annual Number of Responses for this IC	252,000	252,000
Annual IC Time Burden (Hours)	55,440	55,440
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B - Medical Assessment Form Instructional Letter for Medical Providers		08/02/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].