Information Collection

Medical History and Examination for Foreign Service

IC 14884 under ICR 201109-1405-003 · OMB 1405-0068.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0068 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-1622 Medical History and Examination for Foreign Service	Form and Instruction
DS-1622 MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE - Ch ds1622.pdf	Form and Instruction
DS-1622P PRE-EMPLOYMENT MEDICAL HISTORY AND EXAMINATION FOR FOREI ds1622p.pdf	Form and Instruction
DS-1843 MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE for ds1843.pdf	Form and Instruction
DS-1843P PRE-EMPLOYMENT MEDICAL HISTORY AND EXAMINATION FOR FOREI ds1843p.pdf	Form and Instruction

IC Title:

Medical History and Examination for Foreign Service

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-1622	MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE - Children 11 Years and Under	ds1622.pdf	Yes	No	Fillable Printable
Form and Instruction	DS-1622P	PRE-EMPLOYMENT MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE - Children 11 Years and Under	ds1622p.pdf	Yes	No	Fillable Printable
Form and Instruction	DS-1843	MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE for Individuals Age 12 and Older	ds1843.pdf	Yes	No	Fillable Printable
Form and Instruction	DS-1843P	PRE-EMPLOYMENT MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE for Individuals Age 12 and Older	ds1843p.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	8,000	766	7,234
Annual IC Time Burden (Hours)	8,000	766	7,234
Annual IC Cost Burden (Dollars)	0	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.