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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Department of Defense Medical Examination Review Board Medical Information Collection Forms
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
DD Form 2351
DoD Medical Examination Review Board (DoDMERB) Report of Medical Examination
dd2351.pdf
Yes
No
Fillable Printable
Form
DD Form 2369
DoD Medical Examination Review Board (DoDMERB) Cycloplegic Refraction
dd2369.pdf
Yes
No
Fillable Printable
Form
DD Form 2370
DoD Medical Examination Review Board (DoDMERB) Three Day Blood Pressure and Pulse Check
dd2370.pdf
Yes
No
Fillable Printable
Form
DD Form 2372
DoD Medical Examination Review Board (DoDMERB) Statement of Present Health
dd2372.pdf
Yes
No
Fillable Printable
Form
DD Form 2374
DoD Medical Examination Review Board (DoDMERB) Heart Murmur Evaluation
dd2374.pdf
Yes
No
Fillable Printable
Form
DD Form 2378
DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Headaches
dd2378.pdf
Yes
No
Fillable Printable
Form
DD Form 2379
DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Head Injury
dd2379.pdf
Yes
No
Fillable Printable
Form
DD Form 2380
DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Sleepwalking
dd2380.pdf
Yes
No
Fillable Printable
Form
DD Form 2381
DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Motion Sickness
dd2381.pdf
Yes
No
Fillable Printable
Form
DD Form 2382
DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Allergies
dd2382.pdf
Yes
No
Fillable Printable
Form
DD Form 2489
DoD Medical Examination Review Board (DoDMERB) Farnsworth lantern and Red/Green Color Vision Tests
dd2489.pdf
Yes
No
Fillable Printable
Form
DD Form 2492
DoD Medical Examination Review Board (DoDMERB) Report of Medical History
dd2492.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
30,000
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
30,000
0
0
0
0
30,000
Annual IC Time Burden (Hours)
30,000
0
0
0
0
30,000
Annual IC Cost Burden (Dollars)
300,000
0
0
300,000
0
0
Documents for IC
Title
Document
Date Uploaded
0704-0396 Signed 83-I
0704-0396 Signed 83-I.pdf
08/29/2006
Authority Links
AUTHORITY LINKS.doc
08/29/2006
DoD Directive 6130.3
d61303p.pdf
08/29/2006
AFJI36-2018
afji36-2018.pdf
08/29/2006
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.