OMB control number
Report of Medical History/Examination
OMB 0990-0324 ยท HHS/HHSDM.
OMB 0990-0324
Health professionals applying to the Corps will be required to complete form PHS-7060. The self-reported medical history form requires 'yes' or 'no' answers. 'Yes' answers will trigger additional questionnaires (PHS-7053-Allergies; PHS-7054 Head Injury; PHS-7055-Injury; PHS-7056-Headache; PHS-7057-Gyn; PHS-7061-Oswesty Low Back). The Medical Evaluation Officer will use the form to determine medical suitability for the Corps.
The latest form for Report of Medical History/Examination expires 2023-09-30 and is listed under ICR 202006-0990-002.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form PHS-6355 Report of Dental Examination | Form |
| Form PHS-7061 Qwestry Low Back Questionnaire | Form |
| Form PHS-7057 GYN Questionnaire | Form |
| Form PHS-7056 Headache Questionnaire | Form |
| Form PHS-7055 Injury Questionnaire | Form |
| Form PHS-7054 Head Injury Questionnaire | Form |
| Form PHS-7053 Allergies Questionnaire | Form |
| Form PHS-6379 Report of Medical Examination | Form |
| 30-day FRN 0990-0324.pdf | Supplementary Document |
 0990-0324Supporting Statement 07-2020.docx | Supporting Statement A |
 Report of Dental Examination |
Form |
| Qwestry Low Back Questionnaire |
Form |
| GYN Questionnaire |
Form |
| Headache Questionnaire |
Form |
| Injury Questionnaire |
Form |
| Head Injury Questionnaire |
Form |
| Allergies Questionnaire |
Form |
| Report of Medical Examination |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202006-0990-002 | Revision of a currently approved collection | 2020-07-27 | Approved without change | |
| 201612-0990-001 | Reinstatement without change of a previously approved collection | 2017-03-13 | Approved without change | |
| 200710-0990-001 | New collection (Request for a new OMB Control Number) | 2007-10-17 | Approved without change |
OMB Details
Report of Medical Examination
Federal Enterprise Architecture: General Government - Central Records & Statistical Mgt
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form PHS-6379 | Medical History Record | Fillable Fileable | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.