Medical History and Examination for Foreign Service

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-1843 Medical History and Examination for Foreign Service	Form and Instruction	Modified	Available
Form DS-1843 Medical History and Examination for Foreign Service (For Individuals Age 12 and Over)	Form and Instruction	Modified	Available
Form DS-1622 Medical History and Examination for Foreign Service (For Children 11 Years and Under)	Form and Instruction	Modified	Available
Justifications for Changes to DS-1843.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-02-20	Available
DS-1843 Revised 2-19-2015.pdf	Supplementary Document	Uploaded 2015-02-20	Available
Form DS-1843 (2-25-14).pdf	Supplementary Document	Uploaded 2014-02-25	Available
LegalAuthorities 2-25-14.docx	Supplementary Document	Uploaded 2014-02-25	Available
1405-0068 Supporting Statement 2-20-2015.docx	Supporting Statement A	Uploaded 2015-02-20	Available
Policy Memo on MED Clearance Forms (8-29-2013).pdf	Supplementary Document	Uploaded 2013-09-11	Available
Justification for Emergency Review revised (8.28.13).docx	Supplementary Document	Uploaded 2013-09-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
14884	Medical History and Examination for Foreign Service	Form and Instruction	Modified	Medical History and Examination for Foreign Service
14884	Medical History and Examination for Foreign Service	Form and Instruction	Modified	Medical History and Examination for Foreign Service (For Individuals Age 12 and Over)
14884	Medical History and Examination for Foreign Service	Form and Instruction	Modified	Medical History and Examination for Foreign Service (For Children 11 Years and Under)

ICR Details

OMB Control No: 1405-0068	ICR Reference No: 201502-1405-005
Status: Historical Active	Previous ICR Reference No: 201402-1405-004
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical History and Examination for Foreign Service
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/02/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/20/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	06/30/2017	06/30/2017
Responses	23,245	0	23,245
Time Burden (Hours)	23,245	0	23,245
Cost Burden (Dollars)	0	0	0

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Abstract: Pursuant to 22 U.S.C. § 4084, the Secretary of State has the authority to establish a Medical Program. This information collection provides to the U.S. Department of State's Office of Medical Services the material needed to determine whether a candidate for a Foreign Service appointment is able to obtain the medical clearance that is a requirement for that appointment, and to determine the appropriate medical clearances for other individuals who participate in the Medical Program.

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Authorizing Statute(s): PL: Pub.L. 110 - 233 122 Name of Law: Genetic Information Nondiscrimination Act of 2008
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 159	08/16/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	70 FR 37	02/25/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Medical History and Examination for Foreign Service	DS-1843, DS-1622 , DS-1843	Medical History and Examination for Foreign Service (For Children 11 Years and Under) ,   Medical History and Examination for Foreign Service (For Individuals Age 12 and Over) ,   Medical History and Examination for Foreign Service

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ICR Summary of Burden

table that charts list of burden

	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	23,245	23,245	0	0	0	0
Annual Time Burden (Hours)	23,245	23,245	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $373,081

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 02/20/2015

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