# Public Information Collection Requirement Submitted to the Office of Management and Budget (OMB) for Review

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URL: https://www.frixlaw.com/law-library/documents/fr%3A94-16191

## Record

- **Collection:** Federal Register
- **Document type:** Uncategorized Document
- **Published:** July 5, 1994

## Text

DEPARTMENT OF DEFENSE

Public Information Collection Requirement Submitted to the Office
of Management and Budget (OMB) for Review

action: Notice.

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The Department of Defense has submitted to OMB for clearance, the
following proposal for collection of information under the provisions
of the Paperwork Reduction Act (44 U.S.C. Chapter 35).
Title and Applicable Form: Medical Treatment Facility Incident
Statement; Air Force Form 765.
Type of Request: New collection.
Number of Respondents: 13,200.
Responses per Respondent: 1.
Annual Responses: 13,200.
Average Burden per Response: 5 minutes.
Annual Burden Hours: 1,056.
Needs and Uses: The Air Force Form 765, ``Medical Treatment
Facility Incident Statement,'' is completed by hospital personnel on
behalf of patients, who may be non-governmental personnel, to document
adverse events or specific incidents inconsistent with routine medical
treatment facility operations or patient care.
Affected Public: Individuals or households; Federal agencies or
employees.
Frequency: On occasion.
Respondent's Obligation: Voluntary.
OMB Desk Officer: Mr. Edward C. Springer.
Written comments and recommendations on the proposed information
collection should be sent to Mr. Springer at the Office of Management
and Budget, Desk Officer for DoD, Room 3235, New Executive Office
Building, Washington, DC 20503.
DOD Clearance Officer: Mr. William P. Pearce.
Written requests for copies of the information collection proposal
should be sent to Mr. Pearce, WHS/DIOR, 1215 Jefferson Davis Highway,
Suite 1204, Arlington, VA 22202-4302.

Dated: June 29, 1994.
Patricia L. Toppings,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 94-16191 Filed 7-1-94; 8:45 am]
BILLING CODE 5000-04-M

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/fr%3A94-16191. Public record. Not legal advice.