OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medical History and Examination

IC 279415 under ICR 202603-1405-001 · OMB 1405-0068.

Documents and Forms
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Information Collection (IC) Details

View Information Collection (IC)

Medical History and Examination
 
No New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form DS-1622 MEDICAL HISTORY AND EXAMINATION FOR CHILDREN AGE 11 AND YOUNGER ds1622_2026 revisions.docx Yes No Fillable Fileable
Form DS-1843 MEDICAL HISTORY AND EXAMINATION FOR INDIVIDUALS AGE 12 AND OLDER ds1843_2026 revisions.docx Yes No Fillable Fileable

Health Health Care Services

MEDICAL HISTORY AND EXAMINATION   90 FR 58725

2,039 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,039 0 -522 2,561 0 0
Annual IC Time Burden (Hours) 2,039 0 -522 2,561 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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