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Injury Questionnaire
Report of Medical History/Examination
OMB: 0990-0324
IC ID: 182398
OMB.report
HHS/HHSDM
OMB 0990-0324
ICR 202006-0990-002
IC 182398
( )
Documents and Forms
Document Name
Document Type
Form PHS-7055
Injury Questionnaire
Form
PHS-7055 Injury
PHS-7055-Injury Questionnaire
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Injury Questionnaire
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:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
PHS-7055
Injury
PHS-7055-Injury Questionnaire
No
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
General Government
Subfunction:
Central Records & Statistical Mgt
Privacy Act System of Records
Title:
PHS Commissioned Corps Medical Records
FR Citation:
63 FR 68596
Number of Respondents:
2,800
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
0
0
-2,800
0
0
2,800
Annual IC Time Burden (Hours)
0
0
-327
0
0
327
Annual IC Cost Burden (Dollars)
0
0
0
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.
