Health History Form

Peace Corps Health History Form

⚠️ Notice: This information collection may be referencing outdated material.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 0420-0510 Health History Form Form and Instruction
0420-0510 Health History Form HHF 2016.pdf Form and Instruction
HHF 2016.pdf Health History Form IC Document
HHF Supporting Statement 2016(1).docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Health History Form	Agency IC Tracking Number:	PC1789

Is this a Common Form? Yes		IC Status: New

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	0420-0510	Health History Form	HHF 2016.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	23,000	23,000
Annual IC Time Burden (Hours)	17,250	17,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Health History Form	HHF 2016.pdf	11/02/2016
Supporting Statement	HHF Supporting Statement 2016(1).docx	11/02/2016

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