Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Asthma Evaluation Form New 1400 2450 0 Form and Instruction PC-262-2 Asthma Evaluation Form
Cervical Cancer Screening Form New 7200 8400 0 Form and Instruction PC-262-11 Cervical Cancer Screening Form
Colon Cancer Screening Form New 575 1581 0 Form and Instruction PC-262-9 Colon Cancer Screening Form
Diabetes Diagnosis Form New 110 193 0 Form and Instruction PC-262-3 Diabetes Evaluation Form
ECG Form New 1150 767 0 Form and Instruction PC-262-7 Electrocardiogram (ECG/EKG) Form
Eating Disorder Treatment Summary Form New 564 1551 0 Form and Instruction PC-262-8 Eating Disorder Treatment
Functional Abilities Evaluation Form New 600 1350 0 Form and Instruction PC-262-15 Functional Abilities Evaluation Form
Insulin Dependent Supplemental Documentation Form New 28 61 0 Form and Instruction PC-262-10 Insulin Dependent Supplemental Documentation Form
Mammogram Waiver Form New 148 259 0 Form and Instruction PC-355-2 Mammogram Waiver Form
Mental Health Current Evaluation and Treatment Summary New 2442 6716 0 Form and Instruction PC-262-14 Mental Health Current Evaluation and Treatment Summary Form
Prescription for Eyeglasses Form New 6586 8233 0 Form and Instruction PC-OMS-116 Prescription for Eyeglasses Form
Reactive Tuberculin Test Evaluation Form New 784 1764 0 Form and Instruction PC-262-12 Reactive Tuberculin Test Evaluation Form
Required Peace Corps Immunizations Form New 5600 5600 0 Form and Instruction PC-262-16 Vaccination Requirement Form
Substance-Related and Addictive Disorders Current Evaluation Form New 746 2798 0 Form and Instruction PC-262-6 Substance-Related and Addictive Disorders Current Evaluation Form
Transfer of Care New 2540 4445 0 Form and Instruction PC-262-13 Transfer of Care
Total burden requested under this ICR: 30473 46168 0  
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