Health Assessment Form

Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0509 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Health Assessment Form Form
1 Health Assessment Form Health Assessment Form (Clean).docx Form

Information Collection (IC) Details

IC Title:	Health Assessment 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	1	Health Assessment Form	Health Assessment Form (Clean).docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title: ORR Division of Children's Services Records	FR Citation: 81 FR 46682

Number of Respondents: 195	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, 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	105,690	5,370	100,320
Annual IC Time Burden (Hours)	38,048	16,981	21,067
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.