Information Collection Request
Medical History and Examination
ICR 202307-1405-001 · OMB 1405-0068 · Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1405-0068 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form DS-1622 Medical History and Examination |
Form and Instruction | Modified | Available |
| Form DS-1622 Medical History and Examination |
Form and Instruction | Modified | Missing upstream |
 Non - Substantive change DS-1843.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2023-07-10 | Available |
| Non - Substantive change DS-1843.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2023-07-10 | Repair queued |
 1405-0068 30-day Published.pdf |
Supplementary Document | Uploaded 2023-01-26 | Repair queued |
| 1405-0068 30-day Published.pdf |
Supplementary Document | Uploaded 2023-01-26 | Repair queued |
| 11917_PublishedFR_11-14-2022.pdf |
Supplementary Document | Uploaded 2023-01-26 | Repair queued |
| 11917_PublishedFR_11-14-2022.pdf |
Supplementary Document | Uploaded 2023-01-26 | Repair queued |
| Legal Authorities 1405-0068.docx |
Supplementary Document | Uploaded 2023-01-26 | Available |
| Legal Authorities 1405-0068.docx |
Supplementary Document | Uploaded 2023-01-26 | Repair queued |
| 30 day Supporting Statement 1405-0068.docx |
Supporting Statement A | Uploaded 2023-04-03 | Available |
| 30 day Supporting Statement 1405-0068.docx |
Supporting Statement A | Uploaded 2023-04-03 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 14884 |  Medical History and Examination |
Form and Instruction | Modified | |
| 14884 | Medical History and Examination |
Form and Instruction | Modified |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | STATE/AFA |
| OMB Control No | 1405-0068 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202301-1405-006 |
| Date Submitted to OIRA | 2023-07-10 |
| Requested Expiration Date | 1969-12-31 |