Professional Qualifications Medical/Peer Reviewers

Professional Qualifications, Medical and Peer Reviewers

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0005 can be found here:

Documents and Forms

Document Name Document Type
Form DHA 780 Professional Qualifications Medical/Peer Reviewers Form
DHA 780 Professional Qualifications Medical Peer Reviewers DHA780_ProfQualMedPeerReview_20200817_DRAFT.pdf Form
DHA 780 Professional Qualifications Medical Peer Reviewers DHA780_ProfQualMedPeerReview_20200817_DRAFT.pdf Form
Privacy Act Review - No PAS Needed.docx Privacy Act Review - PAS Not Required IC Document
Privacy Act Review - No PAS Needed.docx Privacy Act Review - PAS Not Required IC Document
Instructions for DHA 780.pdf Instructions IC Document
Instructions for DHA 780.pdf Instructions IC Document

Information Collection (IC) Details

IC Title:	Professional Qualifications Medical/Peer Reviewers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	DHA 780	Professional Qualifications Medical Peer Reviewers	DHA780_ProfQualMedPeerReview_20200817_DRAFT.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60	0	60
Annual IC Time Burden (Hours)	20	0	20
Annual IC Cost Burden (Dollars)	2,000	200	1,800

Documents for IC

Title	Document	Date Uploaded
Privacy Act Review - PAS Not Required	Privacy Act Review - No PAS Needed.docx	02/09/2021
Instructions	Instructions for DHA 780.pdf	02/09/2021

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