Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Allergies Questionnaire New 800 80 0 Form PHS-7053
GYN Questionnaire New 600 50 0 Form PHS-7057
Head Injury Questionnaire New 1320 132 0 Form PHS-7054
Headache Questionnaire New 1600 187 0 Form PHS-7056
Injury Questionnaire New 2800 327 0 Form PHS-7055
Medical History Report New 4000 1000 0 Form PHS-7060
Qwestry Low Back Questionnaire New 2000 333 0 Form PHS-7061
Report of Medical Examination New 4000 1000 0 Form PHS-7059
Total burden requested under this ICR: 17120 3109 0  
To view an IC, click on IC Title