Information Collection

Health Status Review

IC 917 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⚠️ Notice: This information collection may be referencing outdated material.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-1789 Health Status Review	Form and Instruction
PC-1789 Health Status Review 0420-0510 Health Status Review Brochure.pdf	Form and Instruction

IC Title:

Health Status Review

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-1789	Health Status Review	0420-0510 Health Status Review Brochure.pdf		Yes	Yes	Fillable Fileable

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: 9,700

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 93 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,700	-12,000	21,700
Annual IC Time Burden (Hours)	7,275	-6,000	13,275
Annual IC Cost Burden (Dollars)	0	-564,000	564,000

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.