Information Collection

Health History Form (PC 1789)

IC 200891 under ICR 201610-0420-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

IC Title:

Health History Form (PC 1789)

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	Requested	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

table that charts IC Documents
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.