Medical History and Examination

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0068 can be found here:

Documents and Forms

Document Name Document Type
Form DS-1622 Medical History and Examination Form and Instruction
Form DS-1622 Medical History and Examination Form and Instruction
DS-1622 Medical History and Examination for Children Age 11 and DS-1622.pdf Form and Instruction
DS-1622 Medical History and Examination for Children Age 11 and DS-1622.pdf Form and Instruction
DS-1843 Medical History and Examination for Individuals Age 12 a DS-1843 updated.pdf Form and Instruction
DS-1843 Medical History and Examination for Individuals Age 12 a DS-1843 updated.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical History and Examination	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-1622	Medical History and Examination for Children Age 11 and Younger	DS-1622.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	DS-1843	Medical History and Examination for Individuals Age 12 and Older	DS-1843 updated.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,561	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,561	2,561
Annual IC Time Burden (Hours)	2,561	2,561
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.