Information Collection

Report of Medical Examination

IC 183919 under ICR 200705-0420-010 · OMB 0420-0510.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0420-0510 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form PC-1790S Report of Medical Examination	Form and Instruction
PC-1790S Report of Medical Exam Form PC-OMS-1790S Report of Medical Examination.pdf	Form and Instruction

IC Title:

Report of Medical Examination

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	PC-1790S	Report of Medical Exam Form	PC-OMS-1790S Report of Medical Examination.pdf		No		Paper Only

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records

Title: Volunteer Applicant and Service Records System (PC-17)

FR Citation: 70 FR 1

Number of Respondents: 6,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	3,000	3,000
Annual IC Cost Burden (Dollars)	312,000	312,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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