Information Collection

Health History Form (PC 1789)

IC 200891 under ICR 201612-0420-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 2016 Update.pdf	Form and Instruction
HHF Changes to OMB draft.docx Changes to HHF	IC Document
Justification for revised HHF.docx Justification for changes	IC Document
HHF Supporting Statement.docx Supporting Statement	IC Document

IC Title:

Health History Form (PC 1789)

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

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 2016 Update.pdf		Yes	Yes	Fillable Fileable

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: 23,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	23,000	13,000	10,000
Annual IC Time Burden (Hours)	17,250	9,750	7,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Changes to HHF	HHF Changes to OMB draft.docx	02/07/2017
Justification for changes	Justification for revised HHF.docx	02/07/2017
Supporting Statement	HHF Supporting Statement.docx	02/10/2017

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