Functional Abilities Evaluation Form

Individual Specific Medical Evaluation Forms (15)

OMB: 0420-0550

IC ID: 224325

Documents and Forms
Information Collection (IC) Details

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Functional Abilities Evaluation Form PC-262-15
 
Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction PC-262-15 Functional Abilities Evaluation Form Functional_Abilities_Evaluation.docx Yes No Fillable Printable

International Affairs and Commerce International Development and Humanitarian Aid

 

300 0
   
Individuals or Households
 
   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 300 0 0 0 0 300
Annual IC Time Burden (Hours) 225 0 0 0 0 225
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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