Information Collection

Medical History and Examination

IC 14884 under ICR 202008-1405-002 · OMB 1405-0068.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0068 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-1622 Medical History and Examination	Form and Instruction
DS-1622 Medical History and Examination for Children Age 11 and DS1622 draft 8-13-2020.pdf	Form and Instruction
DS-1843 Medical History and Examination for Individuals Age 12 a DS1843 draft 8-13-2020.pdf	Form and Instruction

IC Title:

Medical History and Examination

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	DS-1622	Medical History and Examination for Children Age 11 and Younger	DS1622 draft 8-13-2020.pdf		Yes	Yes	Fillable Printable
Form and Instruction	DS-1843	Medical History and Examination for Individuals Age 12 and Older	DS1843 draft 8-13-2020.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,039

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,039	-5,775	7,814
Annual IC Time Burden (Hours)	2,039	-5,775	7,814
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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