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Mammogram Form
Individual Specific Medical Evaluation Forms (15)
OMB: 0420-0550
IC ID: 201714
OMB.report
PEACE
OMB 0420-0550
ICR 201808-0420-004
IC 201714
( )
Documents and Forms
Document Name
Document Type
Form PC-355-2
Mammogram Form
Form and Instruction
PC-355-2 Mammogram Waiver Form
Mammogram_Waiver.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Mammogram Form
Agency IC Tracking Number:
PC-355-2
IC Status:
Unchanged
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
PC-355-2
Mammogram Waiver Form
Mammogram_Waiver.docx
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
International Affairs and Commerce
Subfunction:
International Development and Humanitarian Aid
Privacy Act System of Records
Title:
Mammogram Waiver Form
FR Citation:
70 FR 1
Number of Respondents:
148
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
148
0
0
0
0
148
Annual IC Time Burden (Hours)
259
0
0
0
0
259
Annual IC Cost Burden (Dollars)
0
0
0
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.