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 under

ICR 200207-1405-001 · 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
14883 Medical History and Examination for Foreign Service-For persons 12 years and over Medical History and Examination for Foreign Service-For children 11 years under Form Migrated
ICR Details
1405-0068 200207-1405-001
Historical Active 200109-1405-005
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 under
Extension without change of a currently approved collection   No
Regular
Approved without change 09/27/2002
Retrieve Notice of Action (NOA) 07/19/2002
  Inventory as of this Action Requested Previously Approved
09/30/2005 09/30/2005 09/30/2002
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 assignment, hiring and retirement decisions to be made. Upon completion by the examinee, caregiver, and examiner, medically confidential information is included that should not be transmitted via the Intranet or Internet. By law, they can be reviewd only by the examinee and his or her designated caregiver unless expressed written permission is granted by the examinee.
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.
07/19/2002