Report of Medical History/Examination

ICR 202006-0990-002

OMB: 0990-0324

Federal Form Document

IC Document Collections
ICR Details
0990-0324 202006-0990-002
Active 201612-0990-001
HHS/HHSDM
Report of Medical History/Examination
Revision of a currently approved collection   No
Regular
Approved without change 09/03/2020
Retrieve Notice of Action (NOA) 07/27/2020
  Inventory as of this Action Requested Previously Approved
09/30/2023 36 Months From Approved 09/30/2020
1,000 0 14,120
1,000 0 4,109
0 0 0

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.

US Code: 37 USC 101 Name of Law: Uniformed Services of the United States
   US Code: 42 USC 204 Name of Law: Corps
  
None

Not associated with rulemaking

  85 FR 20281 04/10/2020
85 FR 44310 07/22/2020
No

  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 1,000 14,120 0 -13,120 0 0
Annual Time Burden (Hours) 1,000 4,109 0 -3,109 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Cutting Redundancy
The program changes includes the restructuring of CCHQ. In the previous collection, the Recruitment Branch performed review of medical documents submitted by applicants applying to the Corps to ensure applicants meet medical accession standards. With the restructuring of CCHQ, the Medical Affairs Branch (MAB) is responsible for the medical accession of applicants. Additionally, CCHQ entered into agreement with the Department of Defense Medical Examination Review Board (DoDMERB) and the Department of Defense Medical Exam Testing System (DoDMETS). DoDMETS will coordinate scheduling and conducting medical examinations and forward the examinations electronically to DoDMERB for review. Additionally, MAB retired PHS forms of PHS-7059 (Report of Medical Examination), PHS-6379 Supplemental Medical History Record Required of Applicants to the Public Health Service Commissioned Corps; Form PHS-7053 (Allergies Questionnaire) PHS-7054 (Head Injury Questionnaire), PHS-7055 (Injury Questionnaire), PHS-7056 (Headache Questionnaire), PHS-7057 (GYN Questionnaire), PHS-7061 (Owestr Low Back Questionnaire)

$50,000
No
    Yes
    Yes
No
No
No
No
Sherette Funn-Coleman

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/27/2020


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