Information Collection

Job Corps Health Questionnaire

IC 12954 under ICR 202503-1205-004 · OMB 1205-0033.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ETA 653 Job Corps Health Questionnaire	Form and Instruction
Form ETA 653 Job Corps Health Questionnaire Job Corps Health Questionnaire	Form and Instruction
ETA 653 Job Corps Health Questionnaire ETA 653_EO 14168 Changes.docx	Form and Instruction
ETA 653 Job Corps Health Questionnaire ETA 653_EO 14168 Changes.docx	Form and Instruction

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: 20 CFR 670.965

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 and Instruction	ETA 653				Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title: DOL/GOVT-2

FR Citation: 81 FR 25765

Number of Respondents: 66,630

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	66,630	66,630
Annual IC Time Burden (Hours)	16,658	16,658
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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