Medical History and Examination for Foreign Service

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-1843P Medical History and Examination for Foreign Service	Form and Instruction	Modified	Available
3000 Clinical INDEX.doc	Supplementary Document	Uploaded 2010-12-16	Available
3007.2 GINA Patient Form.docx	Supplementary Document	Uploaded 2010-12-16	Available
DS-1843P.pdf	Supplementary Document	Uploaded 2010-09-15	Available
DS-1843.pdf	Supplementary Document	Uploaded 2010-09-15	Available
DS-1622P.pdf	Supplementary Document	Uploaded 2010-09-15	Available
DS-1622.pdf	Supplementary Document	Uploaded 2010-09-15	Available
Legal Authorities.doc	Supplementary Document	Uploaded 2009-02-25	Available
Supporting Statement_DS 1622_09_08 (2) (2).doc	Supporting Statement A	Uploaded 2009-02-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
14884	Medical History and Examination for Foreign Service	Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0068	ICR Reference No: 201009-1405-003
Status: Historical Inactive	Previous ICR Reference No: 200902-1405-006
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical History and Examination for Foreign Service
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 03/08/2011
	Date Received in OIRA: 10/25/2010
Terms of Clearance: The Department of State has withdrawn this revision request and will continue to use the existing OMB-approved form.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2012	36 Months From Approved	04/30/2012
Responses	7,234	0	7,234
Time Burden (Hours)	7,234	0	7,234
Cost Burden (Dollars)	0	0	0

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Abstract: Form DS-1622(P) and DS-1843(P) are designed to collect medical information to provide medical providers with current and adequate information to base decisions on medical suitability for a federal employee and family members for assignment abroad. DS-1622 is for Children 11 years and under. DS-1843 is for Children 12 years and older. All forms will allow medical personnel to verify that there are sufficient medical resources at a diplomatic mission abroad to maintain the health and fitness of the individual and family members within the Department of State medical program.

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Authorizing Statute(s): US Code: 22 USC 3901 Name of Law: Foreign Service Act of 1980
   US Code: 22 USC 2651 Name of Law: Basic Authorities Act of 1956
  

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:
	75 FR 122	06/25/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 176	09/13/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Medical History and Examination for Foreign Service	DS-1843P, DS-1622P, DS-1622, DS-1843	Pre-Employment Medical History and Examination for Foreign Service For Children 12 Years and Over ,   Medical History and Examination for Foreign Service for Children 11 Years and Under ,   Pre-Employment Medical History and Examination for Foreign Service For Children 11 Years and Under ,   Medical History and Examination For Foreign Service For Individuals Age 12 and Older

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: The increase represents better estimates based on data since the last submission.

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Annual Cost to Federal Government: $364,362

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? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 10/25/2010

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