Information Collection

Medical History and Examination for Foreign Service

IC 14884 under ICR 201308-1405-006 · OMB 1405-0068.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0068 can be found here:

Documents and Forms

Document Name Document Type
Form DS-1622 Medical History and Examination for Foreign Service Form and Instruction
DS-1622 Medical History and Examination for Foreign Service (For ds1622updated - Design Mode.pdf Form and Instruction
DS-1843 Medical History and Examination for Foreign Service (For ds1843updated - Design Mode.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical History and Examination for Foreign Service	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-1622	Medical History and Examination for Foreign Service (For Children 11 Years and Under)	ds1622updated - Design Mode.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	DS-1843	Medical History and Examination for Foreign Service (For Individuals Age 12 and Over)	ds1843updated - Design Mode.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23,245	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 5 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	23,245	15,245	8,000
Annual IC Time Burden (Hours)	23,245	15,245	8,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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