[NCEZID] Statement in Support of Application for Waiver of Inadmissibility Under Immigration and Nationality Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0006 STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY - Revised 21JUL2025	Form and Instruction	Modified	Available
Form 4.422-1 STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY	Form and Instruction	Modified	Available
Form 4.422-1 Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)	Form and Instruction	Modified	Repair queued
Change Request Memo_4.422_July 2025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-07-21	Repair queued
Change Request Memo_4.422_July 2025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-07-21	Repair queued
Attachment F Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-01-17	Repair queued
Attachment F Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2024-01-17	Missing upstream
Attachment D Human Research Determination.pdf	Supplementary Document	Uploaded 2024-01-02	Available
Attachment D Human Research Determination.pdf	Supplementary Document	Uploaded 2024-01-02	Repair queued
Supporting Statement B 2023.docx	Supporting Statement B	Uploaded 2024-01-17	Available
Supporting Statement B 2023.docx	Supporting Statement B	Uploaded 2024-01-17	Missing upstream
Supporting Statement A 2023.docx	Supporting Statement A	Uploaded 2024-01-17	Available
Supporting Statement A 2023.docx	Supporting Statement A	Uploaded 2024-01-17	Repair queued
Attachment A3 8 CFR 212.7 Waiver of certain grounds of excludability.pdf	Supplementary Document	Uploaded 2024-01-17	Available
Attachment A3 8 CFR 212.7 Waiver of certain grounds of excludability.pdf	Supplementary Document	Uploaded 2024-01-17	Repair queued
Attachment A2 42 CFR Part 34 Medical Examination of Aliens.pdf	Supplementary Document	Uploaded 2024-01-17	Available
Attachment A2 42 CFR Part 34 Medical Examination of Aliens.pdf	Supplementary Document	Uploaded 2024-01-17	Repair queued
Attachment A1 8 USC 1182.pdf	Supplementary Document	Uploaded 2024-01-17	Repair queued
Attachment A1 8 USC 1182.pdf	Supplementary Document	Uploaded 2024-01-17	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6595	Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)	Form and Instruction	Modified	STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY - Revised 21JUL2025
6595	Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)	Form and Instruction	Modified	STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY
6595	Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)	Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0006	ICR Reference No: 202507-0920-015
Status: Active	Previous ICR Reference No: 202401-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-25-0145
Title: [NCEZID] Statement in Support of Application for Waiver of Inadmissibility Under Immigration and Nationality Act
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/09/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/23/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2027	03/31/2027	03/31/2027
Responses	200	0	200
Time Burden (Hours)	33	0	33
Cost Burden (Dollars)	3,260	0	3,260

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Abstract: The goal of this collection is to provide CDC with adequate information to fulfill its responsibilities with regard to the processing of applications for waivers of inadmissibility on health-related grounds, specifically mental health disorders with associated harmful behaviors. The information collected is required under U.S. immigration law and regulation. CDC uses the information collected in 0920-0006 to review waiver applications for prospective immigrants and refugees to the United States. CDC assists DHS/USCIS in determining whether or not a prospective immigrant or refugee with a Class A health designation, specifically those mental health disorders with associated harmful behavior, may be admitted into the United States. Non-Substantive Change Request is submitted to make minor format changes including email and mailing addresses. There is no anticipated change to the approved burden hours.

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Authorizing Statute(s): US Code: 8 USC 1182 Name of Law: Aliens and Nationality
   US Code: 42 USC 34 Name of Law: Public Health Service Medical Exam of Aliens
   PL: Pub.L. 212 - 7 8 Name of Law: CFR
  

Citations for New Statutory Requirements: US Code: 8 USC 1182 Name of Law: TITLE 8—ALIENS AND NATIONALITY
US Code: 42 USC Part 34 Name of Law: Public Health Service
US Code: 8 USC 212 Name of Law: Department of Homeland Security

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 75593	11/03/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 2956	01/17/2024
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)	0920-0006, 4.422-1	STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY ,   STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY - Revised 21JUL2025

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	200	200	0	0	0	0
Annual Time Burden (Hours)	33	33	0	0	0	0
Annual Cost Burden (Dollars)	3,260	3,260	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $72,634

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/23/2025

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