Information Collection

Medical History And Examination For Foreign Service

IC 169173 under ICR 198904-1405-006 · OMB 1405-0068.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	FORM 264	No	No
Form	DS-1622	No	No
Form	OPTIONAL	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,677	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,677	3,677
Annual IC Time Burden (Hours)	919	919
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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