Report of Medical History/Examination

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form PHS-7061 Qwestry Low Back Questionnaire	Form	New	Available
Form PHS-7057 GYN Questionnaire	Form	New	Repair queued
Form PHS-7056 Headache Questionnaire	Form	New	Available
Form PHS-7055 Injury Questionnaire	Form	New	Available
Form PHS-7054 Head Injury Questionnaire	Form	New	Available
Form PHS-7053 Allergies Questionnaire	Form	New	Available
Form PHS-7060 Medical History Report	Form	New	Repair queued
Form PHS-7059 Report of Medical Examination	Form	New	Available
0990-New Medicalreport-October172007 Ver2.doc	Supporting Statement A	Uploaded 2007-10-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
182401	Qwestry Low Back Questionnaire	Form	New
182400	GYN Questionnaire	Form	New
182399	Headache Questionnaire	Form	New
182398	Injury Questionnaire	Form	New
182397	Head Injury Questionnaire	Form	New
182396	Allergies Questionnaire	Form	New
182395	Medical History Report	Form	New
182394	Report of Medical Examination	Form	New

ICR Details

OMB Control No: 0990-0324	ICR Reference No: 200710-0990-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Report of Medical History/Examination
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/05/2008
	Date Received in OIRA: 10/17/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2011	36 Months From Approved
Responses	17,120	0	0
Time Burden (Hours)	3,109	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Health professionals applying to the Corps will be required to complete form PHS-7060. The self-reported medical history form requires 'yes' or 'no' answers. 'Yes' answers will trigger additional questionnaires (PHS-7053-Allergies; PHS-7054 Head Injury; PHS-7055-Injury; PHS-7056-Headache; PHS-7057-Gyn; PHS-7061-Oswesty Low Back). The Medical Evaluation Officer will use the form to determine medical suitability for the Corps.

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Authorizing Statute(s): US Code: 42 USC 204 Name of Law: Corps
   US Code: 37 USC 101 Name of Law: Uniformed Services of the United States
  

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:
	72 FR 40154	07/23/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 56357	10/03/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Report of Medical Examination	PHS-7059	Medical Examination Report
Medical History Report	PHS-7060	Medical History Report
Allergies Questionnaire	PHS-7053	Allergies Questionnaire
Head Injury Questionnaire	PHS-7054	Head Injury Questionnaire
Injury Questionnaire	PHS-7055	Injury
Headache Questionnaire	PHS-7056	Headache Questionnaire
GYN Questionnaire	PHS-7057	GYN
Qwestry Low Back Questionnaire	PHS-7061	Owestry Low Back Questionnaire

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ICR Summary of Burden

table that charts list 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	17,120	0	0	17,120	0	0
Annual Time Burden (Hours)	3,109	0	0	3,109	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This a new collection

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Annual Cost to Federal Government: $251,713

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? Yes

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: 10/17/2007

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