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Federal forms, ICRs, and supporting documents

OMB control number

Medical History and Examination

OMB 1405-0068 · STATE/AFA.

OMB 1405-0068

Pursuant to 22 U.S.C. § 4084, the Secretary of State has the authority to establish a Medical Program. This information collection provides to the U.S. Department of State’s Office of Medical Services the information needed to determine whether a candidate for a Foreign Service appointment is able to obtain the medical clearance required for that appointment, and to determine the appropriate medical clearances for other individuals who participate in the Medical Program. The information is requested pursuant to the Foreign Service Act of 1980, as amended, in particular 22 U.S.C. §§ 4084, 3901, and 3984. Revisions to the forms are needed to clarify that the information collection is consistent with applicable authorities, including 42 U.S.C. § 2000ff, Title II, and 29 C.F.R. Part 1635.

The latest form for Medical History and Examination expires 2029-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Form
Form
Form
Form and Instruction
Form and Instruction
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Public Comments
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Public Comments
Attachment_B_Executive_Orders_Forced_Labor_Legal_Authority_compressed.pdf (document unavailable)
Public Comments
Attachment_F_ILO_Forced_Labor_Authority_Reference_compressed.pdf (document unavailable)
Public Comments
13902.pdf (document unavailable)
Public Comments
PC_202603-1405-001_041026_045555_1.pdf (document unavailable)
Public Comments
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Public Comments
Poole_Obelisk_CrossAgency_April2026.docx.pdf (document unavailable)
Public Comments
Poole_Obelisk_Enforcement_Architecture_April2026.docx.pdf (document unavailable)
Public Comments
Attachment_F_ILO_Forced_Labor_Authority_Reference_compressed.pdf (document unavailable)
Public Comments
Public Comments
Poole_Obelisk_Enforcement_Architecture_April2026.docx (document unavailable)
Public Comments
Public Comments
Attachment_D_GAO_Federal_Oversight_Reference_compressed.pdf (document unavailable)
Public Comments
Attachment_B_Executive_Orders_Forced_Labor_Legal_Authority_compressed.pdf (document unavailable)
Public Comments
Public Comments
Public Comments
Supplementary Document
Supplementary Document
Justification for No Material/Nonsubstantive Change
Justification for No Material/Nonsubstantive Change
Justification for No Material/Nonsubstantive Change
Justification for No Material/Nonsubstantive Change
Supplementary Document
11917_PublishedFR_11-14-2022.pdf (document unavailable)
Supplementary Document
11917_PublishedFR_11-14-2022.pdf (document unavailable)
Supplementary Document
Supplementary Document
Supporting Statement A
Supporting Statement A
All Historical Document Collections
 Revision of a currently approved collection 2026-03-11
Approved without change
 No material or nonsubstantive change to a currently approved collection 2023-12-17
Approved without change
 No material or nonsubstantive change to a currently approved collection 2023-07-10
Approved with change
 Revision of a currently approved collection 2023-01-26
Approved with change
 Revision of a currently approved collection 2020-08-13
Approved without change
 Revision of a currently approved collection 2017-06-20
Approved without change
 No material or nonsubstantive change to a currently approved collection 2016-03-01
Approved with change
 No material or nonsubstantive change to a currently approved collection 2015-02-20
Approved without change
 Revision of a currently approved collection 2014-02-25
Approved with change
 Revision of a currently approved collection 2013-08-16
Approved without change
 Revision of a currently approved collection 2011-09-20
Withdrawn and continue
 Revision of a currently approved collection 2010-10-25
Approved without change
 Revision of a currently approved collection 2009-02-27
Approved without change
 Extension without change of a currently approved collection 2006-03-24
Approved without change
 Extension without change of a currently approved collection 2002-07-19
Approved without change
 No material or nonsubstantive change to a currently approved collection 2001-09-04
Approved without change
 Extension without change of a currently approved collection 2001-06-21
Approved without change
 Reinstatement with change of a previously approved collection 2001-04-09
Approved without change
 Reinstatement with change of a previously approved collection 1991-09-26
Approved with change
 No material or nonsubstantive change to a currently approved collection 1989-04-19
Approved without change
 New collection (Request for a new OMB Control Number) 1986-12-31
OMB Details

Medical History and Examination

Federal Enterprise Architecture: Health - Health Care Services

Form DS-1843Medical History and Examination for Children age 12 and olderFillable PrintableForm and instruction
Form DS-1622Medical History and Examination for Children age 11 and youngerFillable PrintableForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.