Report of Medical Examination

Peace Corps Volunter Medical Application and Health Status Review

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form PC-1790S Report of Medical Examination Form and Instruction
PC-1790S Report of Medical Examination Physical Exam 090309.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Report of Medical Examination	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection 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 Examination	Physical Exam 090309.pdf		Yes	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: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,000	-6,000	5,000	6,000
Annual IC Time Burden (Hours)	3,750	-6,525	7,275	3,000
Annual IC Cost Burden (Dollars)	260,000	-52,000	0	312,000

Documents for IC

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.