Job Corps Health Questionnaire

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0033 can be found here:

Documents and Forms

Document Name Document Type
Form ETA 653 Job Corps Health Questionnaire Form and Instruction
ETA 653 Health Questionnaire ETA 653 Job Corps Health Questionnaire_FINAL 5.24.17.docx Form and Instruction
ETA 653_(track changes) 5.24.17.docx ETA 653 - Job Corps Health Questionnaire (track changes) IC Document

Information Collection (IC) Details

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

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	66,697	-20,884	87,581
Annual IC Time Burden (Hours)	8,893	1,595	7,298
Annual IC Cost Burden (Dollars)	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.