Information Collection

Peace Corps Volunteer Authorization for Examination and/or Treatment

IC 236890 under ICR 202505-1240-004 · OMB 1240-0059.

Documents and Forms

Document Name Document Type
Form CA-15 Peace Corps Volunteer Authorization for Examination and/or Treatment Form and Instruction
Form CA-15 Peace Corps Volunteer Authorization for Examination And/Or Treatment Peace Corps Volunteer Authorization for Examination and/or Treatment Form and Instruction
CA-15 Peace Corps Volunteer Authorization for Examination And/ CA-15 Form OMB approved.pdf www.ecomp.dol.gov/ Form and Instruction
CA-15 Peace Corps Volunteer Authorization for Examination And/ CA-15 Form OMB approved.pdf www.ecomp.dol.gov/ Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Peace Corps Volunteer Authorization for Examination and/or Treatment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 10.730 20 CFR 10.731

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-15	Peace Corps Volunteer Authorization for Examination And/Or Treatment	CA-15 Form OMB approved.pdf	https://www.ecomp.dol.gov/	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 81 FR 47418

Number of Respondents: 48	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	48	-204	252
Annual IC Time Burden (Hours)	12	-51	63
Annual IC Cost Burden (Dollars)	10	-149	159

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.

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