Peace Corps Health History Form

ICR 201401-0420-004

OMB: 0420-0510

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2012-07-12
Supporting Statement A
2014-02-10
Supplementary Document
2011-06-21
IC Document Collections
IC ID
Document
Title
Status
200891 Modified
ICR Details
0420-0510 201401-0420-004
Historical Active 201201-0420-002
PEACE
Peace Corps Health History Form
Extension without change of a currently approved collection   No
Regular
Approved without change 03/18/2014
Retrieve Notice of Action (NOA) 02/10/2014
  Inventory as of this Action Requested Previously Approved
03/31/2017 36 Months From Approved 03/31/2014
10,000 0 10,000
7,500 0 7,500
0 0 0

All Peace Corps Volunteer applicants must undergo a physical examination prior to service during the application process to ensure good health and be able to serve without undue disruption due to health problems.

US Code: 22 USC 2504(e) Name of Law: Peace Corps Act
  
None

Not associated with rulemaking

  78 FR 72124 12/02/2013
79 FR 7717 02/10/2014
No

1
IC Title Form No. Form Name
Health History Form (PC 1789) PC-1789, PC-1789 Health History Form ,   Health History Form (paper version)

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 10,000 10,000 0 0 0 0
Annual Time Burden (Hours) 7,500 7,500 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$301,250
No
No
No
No
No
Uncollected
Denora Miller 202 692-1236 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/10/2014


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