Information Collection

Health History Form

IC 223819 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.