Health Survey

Morbidity Study of Former Marines, Dependents, and Employees Potentially Exposed to Contaminated Drinking Water at USMC Base Camp Lejeune

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0042 can be found here:

Documents and Forms

Document Name Document Type
Health Survey Form
Health Survey Attachment C Marine Health Survey April 2011.docx Form
Attachment D prenotice and invite ltr USMC 2_11 clean.docx Att D - Invitation Letter IC Document
Attachment F email invite 2_11 clean.doc Att F - Email Invitation IC Document
Attachment G postcard 2_11 clean.doc Att G - Postcard Reminder/Thank you IC Document
Attachment H email reminder 2_11 clean.doc Att H - Email Reminder/Thank you IC Document
Attachment I reminder letter 2_11 clean.doc Att I - Reminder Letter IC Document
Attachment J email reminder 2_11 clean.doc AttJ - Email Reminder IC Document
Attachment K telephone reminder 2_11 clean.doc Att K - Telephone Reminder IC Document
Attachment L Consent for Health Study participnats April 2011.doc Att L - Participant Consent IC Document
Attachment M Consent for registrants April 2011 redline.doc Att M - Registrant Consent IC Document
Attachment E Letters of invitation from ATSDR April 2011.doc Attachment E Letters of invitation from ATSDR April 2011 IC Document

Information Collection (IC) Details

IC Title:	Health Survey	Agency IC Tracking Number:

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	none	Health Survey	Attachment C Marine Health Survey April 2011.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 47,601	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

	Requested	Previously Approved
Annual Number of Responses for this IC	47,601	47,601
Annual IC Time Burden (Hours)	35,701	35,701
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att D - Invitation Letter	Attachment D prenotice and invite ltr USMC 2_11 clean.docx	04/14/2011
Att F - Email Invitation	Attachment F email invite 2_11 clean.doc	04/14/2011
Att G - Postcard Reminder/Thank you	Attachment G postcard 2_11 clean.doc	04/14/2011
Att H - Email Reminder/Thank you	Attachment H email reminder 2_11 clean.doc	04/14/2011
Att I - Reminder Letter	Attachment I reminder letter 2_11 clean.doc	04/14/2011
AttJ - Email Reminder	Attachment J email reminder 2_11 clean.doc	04/14/2011
Att K - Telephone Reminder	Attachment K telephone reminder 2_11 clean.doc	04/14/2011
Att L - Participant Consent	Attachment L Consent for Health Study participnats April 2011.doc	04/14/2011
Att M - Registrant Consent	Attachment M Consent for registrants April 2011 redline.doc	04/14/2011
Attachment E Letters of invitation from ATSDR April 2011	Attachment E Letters of invitation from ATSDR April 2011.doc	04/25/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.