Report of Medical History/Examination

Forms and Documents

Document Name	Status
Form PHS-6355 Report of Dental Examination Form	Unchanged
Form PHS-7061 Qwestry Low Back Questionnaire Form	Removed
Form PHS-7057 GYN Questionnaire Form	Removed
Form PHS-7056 Headache Questionnaire Form	Removed
Form PHS-7055 Injury Questionnaire Form	Removed
Form PHS-7054 Head Injury Questionnaire Form	Removed
Form PHS-7053 Allergies Questionnaire Form	Removed
Form PHS-6379 Report of Medical Examination Form	Removed
30-day FRN 0990-0324.pdf Supplementary Document	2020-07-23
0990-0324Supporting Statement 07-2020.docx Supporting Statement A	2020-07-24

IC Document Collections

IC ID	Document Title	Status
225615	Report of Dental Examination Form	Unchanged
182401	Qwestry Low Back Questionnaire Form	Removed
182400	GYN Questionnaire Form	Removed
182399	Headache Questionnaire Form	Removed
182398	Injury Questionnaire Form	Removed
182397	Head Injury Questionnaire Form	Removed
182396	Allergies Questionnaire Form	Removed
182394	Report of Medical Examination Form	Removed

ICR Details

OMB Control No: 0990-0324	ICR Reference No: 202006-0990-002
Status: Active	Previous ICR Reference No: 201612-0990-001
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Report of Medical History/Examination
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/03/2020
	Date Received in OIRA: 07/27/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2023	36 Months From Approved	09/30/2020
Responses	1,000	0	14,120
Time Burden (Hours)	1,000	0	4,109
Cost Burden (Dollars)	0	0	0

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Abstract: Health professionals applying to the Corps will be required to complete form PHS-7060. The self-reported medical history form requires 'yes' or 'no' answers. 'Yes' answers will trigger additional questionnaires (PHS-7053-Allergies; PHS-7054 Head Injury; PHS-7055-Injury; PHS-7056-Headache; PHS-7057-Gyn; PHS-7061-Oswesty Low Back). The Medical Evaluation Officer will use the form to determine medical suitability for the Corps.

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Authorizing Statute(s): US Code: 37 USC 101 Name of Law: Uniformed Services of the United States
   US Code: 42 USC 204 Name of Law: Corps
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 20281	04/10/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 44310	07/22/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Report of Dental Examination	PHS-6355	Report of Dental Examination
Qwestry Low Back Questionnaire	PHS-7061	Owestry Low Back Questionnaire
Allergies Questionnaire	PHS-7053	Allergies Questionnaire
Report of Medical Examination	PHS-6379	Medical History Record
Head Injury Questionnaire	PHS-7054	Head Injury Questionnaire
Injury Questionnaire	PHS-7055	Injury
GYN Questionnaire	PHS-7057	GYN
Headache Questionnaire	PHS-7056	Headache Questionnaire

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,000	14,120	0	-13,120	0	0
Annual Time Burden (Hours)	1,000	4,109	0	-3,109	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: The program changes includes the restructuring of CCHQ. In the previous collection, the Recruitment Branch performed review of medical documents submitted by applicants applying to the Corps to ensure applicants meet medical accession standards. With the restructuring of CCHQ, the Medical Affairs Branch (MAB) is responsible for the medical accession of applicants. Additionally, CCHQ entered into agreement with the Department of Defense Medical Examination Review Board (DoDMERB) and the Department of Defense Medical Exam Testing System (DoDMETS). DoDMETS will coordinate scheduling and conducting medical examinations and forward the examinations electronically to DoDMERB for review. Additionally, MAB retired PHS forms of PHS-7059 (Report of Medical Examination), PHS-6379 Supplemental Medical History Record Required of Applicants to the Public Health Service Commissioned Corps; Form PHS-7053 (Allergies Questionnaire) PHS-7054 (Head Injury Questionnaire), PHS-7055 (Injury Questionnaire), PHS-7056 (Headache Questionnaire), PHS-7057 (GYN Questionnaire), PHS-7061 (Owestr Low Back Questionnaire)

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Annual Cost to Federal Government: $50,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/27/2020

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