Information Collection

PC 1789 Health History Form 2025

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

PC-1789

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	PC-1789				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 %

table that charts list of burden
	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

table that charts IC Documents
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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