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Medical History and Examination
Medical History and Examination
OMB: 1405-0068
IC ID: 14884
OMB.report
STATE/AFA
OMB 1405-0068
ICR 202307-1405-001
IC 14884
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0068 can be found here:
2023-12-17 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Form DS-1622
Medical History and Examination
Form and Instruction
Form DS-1622
Medical History and Examination
Form and Instruction
DS-1622 Medical History and Examination for Children Age 11 and Younger
DS-1622.pdf
Form and Instruction
DS-1843 Medical History and Examination for Individuals Age 12 and Older
DS-1843 updated.pdf
Form and Instruction
Information Collection (IC) Details
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