Information Collection

Medical History and Examination for Foreign Service

IC 14884 under ICR 201502-1405-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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-1843 Medical History and Examination for Foreign Service	Form and Instruction
DS-1622 Medical History and Examination for Foreign Service (For ds1622updated - Design Mode.pdf	Form and Instruction
DS-1843 Medical History and Examination for Foreign Service (For ds1843updated - Design Mode.pdf	Form and Instruction
DS-1843 Medical History and Examination for Foreign Service DS-1843 Revised 2-19-2015.pdf	Form and Instruction
Justifications for Changes to DS-1843.docx Justification for Changes to DS-1843	IC Document

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: Mandatory

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-1843	Medical History and Examination for Foreign Service (For Individuals Age 12 and Over)	ds1843updated - Design Mode.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	DS-1622	Medical History and Examination for Foreign Service (For Children 11 Years and Under)	ds1622updated - Design Mode.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	DS-1843	Medical History and Examination for Foreign Service	DS-1843 Revised 2-19-2015.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 23,245

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 5 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	23,245	23,245
Annual IC Time Burden (Hours)	23,245	23,245
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification for Changes to DS-1843	Justifications for Changes to DS-1843.docx	04/01/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.