Information Collection

PC 1789 Health History Form 2025

IC 277807 under ICR 202509-0420-001 · OMB 0420-0510.

Documents and Forms

Document Name Document Type
Form PC-1789 Health History Form PC 1789 Health History Form 2025 Form and Instruction
PC-1789 Health History Form PC 1789 Current HHF as of 9-26-2025.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PC 1789 Health History Form 2025	Agency IC Tracking Number:	PC-1789

Is this a Common Form? Yes		IC Status: New

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	PC 1789 Current HHF as of 9-26-2025.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: 79 FR 41599

Number of Respondents: 23,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

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

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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