Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Allergies Questionnaire Unchanged 800 80 0 Form PHS-7053
GYN Questionnaire Unchanged 600 50 0 Form PHS-7057
Head Injury Questionnaire Unchanged 1320 132 0 Form PHS-7054
Headache Questionnaire Unchanged 1600 187 0 Form PHS-7056
Injury Questionnaire Unchanged 2800 327 0 Form PHS-7055
Medical History Report Removed 0 0 0 Form PHS-7060
Qwestry Low Back Questionnaire Unchanged 2000 333 0 Form PHS-7061
Report of Dental Examination New 1000 1000 0 Form PHS-6355
Report of Medical Examination Modified 4000 2000 0 Form PHS-6379
Total burden requested under this ICR: 14120 4109 0  
To view an IC, click on IC Title