Information Collection Request
Medical History and Examination
ICR 202301-1405-006 · OMB 1405-0068 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1405-0068 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form DS-1622 Medical History and Examination |
Form and Instruction | Modified | Repair queued |
 1405-0068 30-day Published.pdf |
Supplementary Document | Uploaded 2023-01-26 | Missing upstream |
| 11917_PublishedFR_11-14-2022.pdf |
Supplementary Document | Uploaded 2023-01-26 | Missing upstream |
 Legal Authorities 1405-0068.docx |
Supplementary Document | Uploaded 2023-01-26 | Repair queued |
| 30 day Updated Supporting Statement 1405-0068.docx |
Supporting Statement A | Uploaded 2023-01-26 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 14884 |  Medical History and Examination |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | STATE/AFA |
| OMB Control No | 1405-0068 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202008-1405-002 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |