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Federal forms, ICRs, and supporting documents

Information Collection

Department of Defense Medical Examination Review Board Medical Information Collection Forms

IC 5465 under ICR 200608-0704-006 · OMB 0704-0396.

Documents and Forms
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IC Document
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Information Collection (IC) Details

View Information Collection (IC)

Department of Defense Medical Examination Review Board Medical Information Collection Forms
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form DD Form 2489 DoD Medical Examination Review Board (DoDMERB) Farnsworth lantern and Red/Green Color Vision Tests dd2489.pdf Yes No Fillable Printable
Form DD Form 2374 DoD Medical Examination Review Board (DoDMERB) Heart Murmur Evaluation dd2374.pdf Yes No Fillable Printable
Form DD Form 2381 DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Motion Sickness dd2381.pdf Yes No Fillable Printable
Form DD Form 2382 DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Allergies dd2382.pdf Yes No Fillable Printable
Form DD Form 2492 DoD Medical Examination Review Board (DoDMERB) Report of Medical History dd2492.pdf Yes No Fillable Printable
Form DD Form 2370 DoD Medical Examination Review Board (DoDMERB) Three Day Blood Pressure and Pulse Check dd2370.pdf Yes No Fillable Printable
Form DD Form 2372 DoD Medical Examination Review Board (DoDMERB) Statement of Present Health dd2372.pdf Yes No Fillable Printable
Form DD Form 2351 DoD Medical Examination Review Board (DoDMERB) Report of Medical Examination dd2351.pdf Yes No Fillable Printable
Form DD Form 2378 DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Headaches dd2378.pdf Yes No Fillable Printable
Form DD Form 2369 DoD Medical Examination Review Board (DoDMERB) Cycloplegic Refraction dd2369.pdf Yes No Fillable Printable
Form DD Form 2379 DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Head Injury dd2379.pdf Yes No Fillable Printable
Form DD Form 2380 DoD Medical Examination Review Board (DoDMERB) Statement of History Regarding Sleepwalking dd2380.pdf Yes No Fillable Printable

Health

 

30,000 0
   
Individuals or Households
 
   0 %

  Approved 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 30,000 0 0 0 0 30,000
Annual IC Time Burden (Hours) 30,000 0 0 0 0 30,000
Annual IC Cost Burden (Dollars) 300,000 0 0 300,000 0 0

Title Document Date Uploaded
0704-0396 Signed 83-I 0704-0396 Signed 83-I.pdf 08/29/2006
Authority Links AUTHORITY LINKS.doc 08/29/2006
DoD Directive 6130.3 d61303p.pdf 08/29/2006
AFJI36-2018 afji36-2018.pdf 08/29/2006
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.