OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Medical History and Examination for Foreign Service - For persons 12 years and over. Medical History and Examination for Foreign Service - For children 11 years and under.

ICR 200106-1405-004 · OMB 1405-0068 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
14882 Medical History and Examination for Foreign Service - For persons 12 years and over. Medical History and Examination for Foreign Service - For children 11 years and under. Form Migrated
ICR Details
1405-0068 200106-1405-004
Historical Active 200104-1405-001
STATE/AFA
Medical History and Examination for Foreign Service - For persons 12 years and over. Medical History and Examination for Foreign Service - For children 11 years and under.
Extension without change of a currently approved collection   No
Regular
Approved without change 08/28/2001
Retrieve Notice of Action (NOA) 06/21/2001
This collection is approved for 1 year. During that time, the State Department must once again review its compliance with the Privacy Act and ensure that respondents are adequately informed of the routine uses of this collection. In particular, the agency must list the routine uses from the System of Records on or with this form. Cross-references to documents not immediately available to the respondent are not a suitable substitute.
  Inventory as of this Action Requested Previously Approved
08/31/2002 08/31/2002 10/31/2001
12,000 0 12,000
12,000 0 12,000
0 0 0
Forms are used by the Health Promotion Program of the Office of Medical Services. They become part of the individual's medical record and are used by the Examination and Clearance Sections medical personnel to enable assignments, hiring and retirement decisions to be made.
None
None
No
  Total Approved 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 12,000 12,000 0 0 0 0
Annual Time Burden (Hours) 12,000 12,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
06/21/2001