Health History Form (PC 1789)

Peace Corps Health History Form

OMB: 0420-0510

IC ID: 200891

Information Collection (IC) Details

View Information Collection (IC)

Health History Form (PC 1789)
 
Yes Modified
 
Voluntary
 

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

International Affairs and Commerce International Development and Humanitarian Aid

PC--17 Volunteer Applicant and Service Records System  70 FR 1

23,000 0
   
Individuals or Households
 
   99 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 23,000 0 13,000 0 0 10,000
Annual IC Time Burden (Hours) 17,250 0 9,750 0 0 7,500
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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