Department of Defense Medical Examination Review Board Medical Information Collection Forms

Forms and Documents

Document Name	Status
Form DD Form 2489 Department of Defense Medical Examination Review Board Medical Information Collection Forms Form	Modified
0704-0396 SS Part A.doc Supporting Statement A	2006-08-28

IC Document Collections

IC ID	Document Title	Status
5465	Department of Defense Medical Examination Review Board Medical Information Collection Forms Form	Modified

ICR Details

OMB Control No: 0704-0396	ICR Reference No: 200608-0704-006
Status: Historical Active	Previous ICR Reference No: 200307-0704-001
Agency/Subagency: DOD/DODDEP	Agency Tracking No:
Title: Department of Defense Medical Examination Review Board Medical Information Collection Forms
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/01/2006
	Date Received in OIRA: 08/29/2006
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2009	36 Months From Approved	10/31/2006
Responses	30,000	0	30,000
Time Burden (Hours)	30,000	0	30,000
Cost Burden (Dollars)	300,000	0	0

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Abstract: Information will be used to access a medical qualification/disqualification status for individuals applying to one or more United States Military Service Academies, Reserve Officer Training Corps (ROTC) College Scholarship Programs, or the Uniformed Services University of Health Sciences (USUHS). Respondents are individuals interested in serving in the military and attending one of the military academies, ROTC College Scholarship Programs, or USUHS.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 36524	06/27/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 50395	08/25/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Department of Defense Medical Examination Review Board Medical Information Collection Forms	DD Form 2489, DD Form 2374, DD Form 2351, DD Form 2370, DD Form 2372, DD Form 2382, DD Form 2492, DD Form 2381, DD Form 2378, DD Form 2369, DD Form 2379, DD Form 2380	DoD Medical Examination Review Board (DoDMERB) Farnsworth lantern and Red/Green Color Vision Tests ,   DoD Medical Examination Review Board (DoDMERB) Heart Murmur Evaluation ,   DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Motion Sickness ,   DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Allergies ,   DoD Medical Examination Review Board (DoDMERB) Report of Medical History ,   DoD Medical Examination Review Board (DoDMERB) Three Day Blood Pressure and Pulse Check ,   DoD Medical Examination Review Board (DoDMERB) Statement of Present Health ,   DoD Medical Examination Review Board (DoDMERB) Report of Medical Examination ,   DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Headaches ,   DoD Medical Examination Review Board (DoDMERB) Cycloplegic Refraction ,   DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Head Injury ,   DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Sleepwalking

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	30,000	30,000	0	0	0	0
Annual Time Burden (Hours)	30,000	30,000	0	0	0	0
Annual Cost Burden (Dollars)	300,000	0	0	0	300,000	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $465,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/29/2006

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