Report of Medical History/Examination

Forms and Documents

Document Name	Status
Form PHS-6355 Report of Dental Examination Form	New
Form PHS-7061 Qwestry Low Back Questionnaire Form	Unchanged
Form PHS-7057 GYN Questionnaire Form	Unchanged
Form PHS-7056 Headache Questionnaire Form	Unchanged
Form PHS-7055 Injury Questionnaire Form	Unchanged
Form PHS-7054 Head Injury Questionnaire Form	Unchanged
Form PHS-7053 Allergies Questionnaire Form	Unchanged
Form PHS-7060 Medical History Report Form	Removed
Form PHS-6379 Report of Medical Examination Form	Modified
60-day Federal Register, Volume 81 Issue 178 (Wednesday, September 14, 2016).htm Supplementary Document	2017-03-10
0990-0324Supporting Statement 03_03 2017 (2).doc Supporting Statement A	2017-03-10

IC Document Collections

IC ID	Document Title	Status
225615	Report of Dental Examination Form	New
182401	Qwestry Low Back Questionnaire Form	Unchanged
182400	GYN Questionnaire Form	Unchanged
182399	Headache Questionnaire Form	Unchanged
182398	Injury Questionnaire Form	Unchanged
182397	Head Injury Questionnaire Form	Unchanged
182396	Allergies Questionnaire Form	Unchanged
182395	Medical History Report Form	Removed
182394	Report of Medical Examination Form	Modified

ICR Details

OMB Control No: 0990-0324	ICR Reference No: 201612-0990-001
Status: Historical Active	Previous ICR Reference No: 200710-0990-001
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Report of Medical History/Examination
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/02/2017
	Date Received in OIRA: 03/13/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2020	36 Months From Approved	03/31/2011
Responses	14,120	0	4,000
Time Burden (Hours)	4,109	0	1,000
Cost Burden (Dollars)	0	0	0

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Abstract: Health professionals applying to the Corps will be required to complete form PHS-7060. The self-reported medical history form requires 'yes' or 'no' answers. 'Yes' answers will trigger additional questionnaires (PHS-7053-Allergies; PHS-7054 Head Injury; PHS-7055-Injury; PHS-7056-Headache; PHS-7057-Gyn; PHS-7061-Oswesty Low Back). The Medical Evaluation Officer will use the form to determine medical suitability for the Corps.

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Authorizing Statute(s): US Code: 42 USC 204 Name of Law: Corps
   US Code: 37 USC 101 Name of Law: Uniformed Services of the United States
  

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:
	81 FR 63192	09/14/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 13352	03/10/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Report of Medical Examination	PHS-6379	Medical History Record
Allergies Questionnaire	PHS-7053	Allergies Questionnaire
Head Injury Questionnaire	PHS-7054	Head Injury Questionnaire
Injury Questionnaire	PHS-7055	Injury
Headache Questionnaire	PHS-7056	Headache Questionnaire
GYN Questionnaire	PHS-7057	GYN
Qwestry Low Back Questionnaire	PHS-7061	Owestry Low Back Questionnaire
Medical History Report	PHS-7060	Medical History Report
Report of Dental Examination	PHS-6355	Report of Dental Examination

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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	14,120	4,000	0	10,120	0	0
Annual Time Burden (Hours)	4,109	1,000	0	3,109	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The program change included the removal of PHS-7059 (Report of Medical Examination) and PHS-7060 (Report of Medical History). These forms were replaced with DD 2807-1 (Report of Medical History). As stated previously, no additional response burden was required because the medical certifications are performed on Department of Defense DoD) forms included in the application process and the response burden is accounted for therein. However, the implementation of PHS-6355 (Report of Dental Examination of Applicants to the Commissioned Corps of the Public Health Service) and PHS-6379 (Supplemental Medical History Record Required of Applicants to the Public Health Service Commissioned Corps) increased the response burden hours. The average amount of time required to complete all forms is included in 12A.

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Annual Cost to Federal Government: $93,530

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? Yes

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: 03/13/2017

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