Information Collection

Health History Form (PC 1789)

IC 200891 under ICR 201401-0420-004 · OMB 0420-0510.

⚠️ Notice: This information collection may be referencing outdated material.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-1789 Health History Form (PC 1789) Form and Instruction
PC-1789 Health History Form HHF (PC 1789).pdf Form and Instruction
PC-1789 Health History Form (paper version) HealthHistory_4_12.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health History Form (PC 1789)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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-1789	Health History Form	HHF (PC 1789).pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	PC-1789	Health History Form (paper version)	HealthHistory_4_12.pdf		No		Paper Only

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records
Title: PC--17 Volunteer Applicant and Service Records System	FR Citation: 70 FR 1

Number of Respondents: 10,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10,000	10,000
Annual IC Time Burden (Hours)	7,500	7,500
Annual IC Cost Burden (Dollars)	0	0

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.