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⚠️ Notice: This information collection may be referencing outdated material.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

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

View Information Collection (IC)

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.