View Information Collection (IC)

View Information Collection (IC)

IC Title:	Job Corps Health Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 670.965

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ETA 653	Health Questionnaire	ETA 653 Job Corps Health Questionnaire_FINAL 5.24.17.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title: DOL/GOVT-2	FR Citation: 81 FR 25765

Number of Respondents: 66,697	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	66,697	0	0	-20,884	0	87,581
Annual IC Time Burden (Hours)	8,893	0	0	1,595	0	7,298
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
ETA 653 - Job Corps Health Questionnaire (track changes)	ETA 653_(track changes) 5.24.17.docx	05/25/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.