Information Collection Request

Medical History and Examination

ICR 202307-1405-001 · OMB 1405-0068 · Active

⚠️ Notice: This information collection may be outdated.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

Forms and Documents

Forms and supporting documents for this ICR
Document	Type	Status	Availability
Form DS-1622 Medical History and Examination	Form and Instruction	Modified	Available
Form DS-1622 Medical History and Examination	Form and Instruction	Modified	Repair queued
Non - Substantive change DS-1843.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-07-10	Available
Non - Substantive change DS-1843.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-07-10	Repair queued
1405-0068 30-day Published.pdf	Supplementary Document	Uploaded 2023-01-26	Available
1405-0068 30-day Published.pdf	Supplementary Document	Uploaded 2023-01-26	Repair queued
11917_PublishedFR_11-14-2022.pdf	Supplementary Document	Uploaded 2023-01-26	Available
11917_PublishedFR_11-14-2022.pdf	Supplementary Document	Uploaded 2023-01-26	Repair queued
Legal Authorities 1405-0068.docx	Supplementary Document	Uploaded 2023-01-26	Available
Legal Authorities 1405-0068.docx	Supplementary Document	Uploaded 2023-01-26	Repair queued
30 day Supporting Statement 1405-0068.docx	Supporting Statement A	Uploaded 2023-04-03	Available
30 day Supporting Statement 1405-0068.docx	Supporting Statement A	Uploaded 2023-04-03	Repair queued

Information collection document groups
IC ID	Collection	Type	Status	Form
14884	Medical History and Examination	Form and Instruction	Modified
14884	Medical History and Examination	Form and Instruction	Modified

Record metadata
Status	Active
Agency/Subagency	STATE/AFA
OMB Control No	1405-0068
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202301-1405-006
Date Submitted to OIRA	2023-07-10
Requested Expiration Date	1969-12-31