Information Collection

Individuals or Households

IC 242629 under ICR 202604-3060-003 · OMB 3060-1246.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FCC Form 5627 Medical Consent Form Individuals or Households	Form
FCC Form 5627 Medical Consent Form Medical Consent 4.23.26.docx	Form

IC Title:

Agency IC Tracking Number:

OWD

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1630

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	FCC Form 5627				Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records

Title: EEOC/GOV-1, Equal Employment Opportunity (EEO) Complaint and Appeal Records

FR Citation: 81 FR 81116

Number of Respondents: 82

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	164	146	18
Annual IC Time Burden (Hours)	425	376	49
Annual IC Cost Burden (Dollars)	1,700	0	1,700

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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