Information Collection

Agent Orange Registry Code Sheet

IC 28576 under ICR 201609-2900-003 · OMB 2900-0376.

Documents and Forms

Document Name Document Type
Form VA Form 10-9009 Agent Orange Registry Code Sheet Form
VA Form 10-9009 Agent Orange Registry Code Sheet VA Form 10-9009.pdf vaww.registries.aac.va.gov Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Agent Orange Registry Code Sheet	Agency IC Tracking Number:	2900-0376

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 10-9009	Agent Orange Registry Code Sheet	VA Form 10-9009.pdf	http://vaww.registries.aac.va.gov	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 24VA10P2, Patient Medical Record â VA	FR Citation: 77 FR 65938

Number of Respondents: 20,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	6,667	6,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.