Information Collection

Initial Medical Exam Form

IC 217788 under ICR 201809-0970-006 · OMB 0970-0466.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0466 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Initial Medical Exam Form Form and Instruction
1 Initial Medical Exam Form Initial Medical Exam_FINAL_03252019.docx Form and Instruction
1 Appendix A Appendix A_Supplemental TB Screening Form_FINAL_03252019.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Initial Medical Exam Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Initial Medical Exam Form	Initial Medical Exam_FINAL_03252019.docx		Yes	Yes	Fillable Fileable
Form and Instruction	1	Appendix A	Appendix A_Supplemental TB Screening Form_FINAL_03252019.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	44,550	4,050	40,500
Annual IC Time Burden (Hours)	13,365	3,240	10,125
Annual IC Cost Burden (Dollars)	0	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.