Medical History and Examination

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
279415	Medical History and Examination Form	New
14884	Medical History and Examination Form and Instruction	Unchanged

ICR Details

OMB Control No: 1405-0068	ICR Reference No: 202603-1405-001
Status: Received in OIRA	Previous ICR Reference No: 202312-1405-003
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical History and Examination
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/11/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2026
Responses	4,600	2,561
Time Burden (Hours)	4,600	2,561
Cost Burden (Dollars)	0	0

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Abstract: Pursuant to 22 U.S.C. § 4084, the Secretary of State has the authority to establish a Medical Program. This information collection provides to the U.S. Department of State’s Office of Medical Services the information needed to determine whether a candidate for a Foreign Service appointment is able to obtain the medical clearance required for that appointment, and to determine the appropriate medical clearances for other individuals who participate in the Medical Program. The information is requested pursuant to the Foreign Service Act of 1980, as amended, in particular 22 U.S.C. §§ 4084, 3901, and 3984. Revisions to the forms are needed to clarify that the information collection is consistent with applicable authorities, including 42 U.S.C. § 2000ff, Title II, and 29 C.F.R. Part 1635.

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Authorizing Statute(s): PL: Pub.L. 110 - 233 122 Name of Law: Genetic Information Nondiscrimination Act of 2008
  

Citations for New Statutory Requirements: None

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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:
	90 FR 12878	12/17/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 12957	03/10/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Medical History and Examination	DS-1843, DS-1622	MEDICAL HISTORY AND EXAMINATION FOR CHILDREN AGE 11 AND YOUNGER ,   MEDICAL HISTORY AND EXAMINATION FOR INDIVIDUALS AGE 12 AND OLDER
Medical History and Examination	DS-1843, DS-1622	Medical History and Examination for Children age 11 and younger ,   Medical History and Examination for Children age 12 and older

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ICR Summary of Burden

	Total Request	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	4,600	2,561	0	-522	2,561	0
Annual Time Burden (Hours)	4,600	2,561	0	-522	2,561	0
Annual Cost Burden (Dollars)	0	0	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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: These forms require a pre-assignment and pre-employment applicant, and their eligible family members, to provide information regarding chronic medical conditions, mental health status, and past mental health treatment. Although not routinely discussed, except with a person’s health care provider, these questions are necessary to gauge the individual and family members’ ability to be assigned to hardship posts, or posts where medical resources are scarce. These forms also might include information regarding special educational needs that a dependent child may have.

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Annual Cost to Federal Government: $30,748

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.     Yes

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: 03/11/2026

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