Report of Medical Examination

Peace Corps Health History Form

⚠️ Notice: This information collection may be referencing outdated material.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: Removed

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 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-5,000	5,000
Annual IC Time Burden (Hours)	-3,750	3,750
Annual IC Cost Burden (Dollars)	-260,000	260,000

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.