Information Collection

Health History Form (PC 1789)

IC 200891 under ICR 202011-0420-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

Information Collection (IC) Details

View Information Collection (IC)

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:

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: 100 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	23,000	0	23,000
Annual IC Time Burden (Hours)	17,250	0	17,250
Annual IC Cost Burden (Dollars)	543,720	543,720	0

Documents for IC

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.