View Information Collection (IC)

View Information Collection (IC)

IC Title:	USM-522A Physician Evaluation Report for USMS Operational Employees	Agency IC Tracking Number:	USMS-2013-1-522A

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	USM-522A	Physician Evaluation Report for USMS Operational Employees	usm522a.pdf		Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: OPM/GOVT-10, Employee Medical File System Records	FR Citation: 65 FR 24732

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

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	300	0	300	0	0	0
Annual IC Time Burden (Hours)	700	0	700	0	0	0
Annual IC Cost Burden (Dollars)	56,700	0	56,700	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.