Information Collection

Report of Medical Examination and Vaccination Record

IC 20305 under ICR 200912-1615-001 · OMB 1615-0033.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1615-0033 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form I-693 Report of Medical Examination and Vaccination Record	Form
I-693 Instructions 12-24-09 (1).pdf	Instruction
I-693 Report of Medical Examination and Vaccination Record I-693 Form 12-24-09.pdf	Form

IC Title:

Report of Medical Examination and Vaccination Record

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 8 CFR 210 8 CFR 245 8 CFR 245a 8 CFR 209 (To search for a specific CFR, visit the Code of Federal Regulations.)

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	I-693	Report of Medical Examination and Vaccination Record	I-693 Form 12-24-09.pdf		Yes	No	Fillable Printable
Instruction			I-693 Instructions 12-24-09 (1).pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 800,000

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	Previously Approved
Annual Number of Responses for this IC	800,000	800,000
Annual IC Time Burden (Hours)	2,000,000	2,000,000
Annual IC Cost Burden (Dollars)	0	0

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.