Information Collection

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

IC 261419 under ICR 202610-0970-004 · OMB 0970-0466.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Medical Assessment Form Medical Assessment Form - Recordkeeping Time (information obtained via health records)	Form
1 Medical Assessment Form ORR Dental 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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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: 500

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
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-50,000	50,000
Annual IC Time Burden (Hours)	-8,500	8,500
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.

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