Medical History and Examination for Foreign Service

Forms and Documents

Document Name	Status
Form DS-1622 Medical History and Examination for Foreign Service Form and Instruction	Modified
Legal Authority for Medical Program.docx Supplementary Document	2011-09-20
Support Statement - Medical Exam and History.docx Supporting Statement A	2011-09-20

IC Document Collections

IC ID	Document Title	Status
14884	Medical History and Examination for Foreign Service Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0068	ICR Reference No: 201109-1405-003
Status: Historical Active	Previous ICR Reference No: 200902-1405-006
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical History and Examination for Foreign Service
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/03/2012
	Date Received in OIRA: 09/20/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2015	36 Months From Approved	04/30/2012
Responses	8,000	0	7,234
Time Burden (Hours)	8,000	0	7,234
Cost Burden (Dollars)	0	0	0

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Abstract: The information is collected for the purpose of making a decision regarding the clearance status of an individual and family members for assignment abroad. The clearance status helps to determine new assignments based on whether or not the level of medical care available in the country and city of the proposed assignment meets the medical care requirements of the individual and family members.

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Authorizing Statute(s): US Code: 22 USC 3901 Name of Law: Foreign Service Act of 1980
   US Code: 22 USC 2651 Name of Law: Basic Authorities Act of 1956
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 122	06/25/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 176	09/12/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medical History and Examination for Foreign Service	DS-1622, DS-1622P, DS-1843P, DS-1843	MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE - Children 11 Years and Under ,   PRE-EMPLOYMENT MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE - Children 11 Years and Under ,   MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE for Individuals Age 12 and Older ,   PRE-EMPLOYMENT MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE for Individuals Age 12 and Older

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ICR Summary of Burden

	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	8,000	7,234	0	0	766	0
Annual Time Burden (Hours)	8,000	7,234	0	0	766	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The annual burden used a refined estimate based upon the number of respondents and an estimate of one hour to gather the information, transcribe the information, print and sign the form, and send it to Medical Clearances.

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Annual Cost to Federal Government: $478,176

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 09/20/2011

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