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Medical Assessment Form - Recordkeeping Time (information obtained via health records)

IC 261419 under ICR 202502-0970-013 · OMB 0970-0466.

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Medical Assessment Form - Recordkeeping Time (information obtained via health records)
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 1 Medical Assessment Form ORR Dental Assessment Form_0970-0466_clean.docx Yes Yes Fillable Fileable

Community and Social Services Social Services

ORR Division of Children's Services Records  81 FR 46682

500 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 50,000 0 0 0 0 50,000
Annual IC Time Burden (Hours) 8,500 0 0 0 0 8,500
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment B - Medical Assessment Form Instructional Letter for Medical Providers Attachment B_Medical Assessment Form Instructional Letter for Medical Providers.docx 08/02/2023
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.