Peace Corps Health History Form

ICR 202509-0420-001

OMB: 0420-0510

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
New
Form and Instruction
Removed
Supporting Statement A
2025-09-30
Supplementary Document
2024-08-23
IC Document Collections
ICR Details
0420-0510 202509-0420-001
Received in OIRA 202407-0420-002
PEACE PC-1789
Peace Corps Health History Form
Reinstatement with change of a previously approved collection   Yes
Regular 09/30/2025
  Requested Previously Approved
36 Months From Approved
23,000 0
17,250 0
0 0

All Peace Corps Volunteer applicants must undergo a physical examination prior to service during the application process to ensure good health and be able to serve without undue disruption due to health problems.

US Code: 22 USC 2504(e) Name of Law: Peace Corps Act
  
None

Not associated with rulemaking

  89 FR 51914 06/20/2024
89 FR 68214 08/23/2024
No

1
IC Title Form No. Form Name
Health History Form (PC 1789) PC-1789 Health History Form
PC 1789 Health History Form 2025 PC-1789 Health History Form

  Total Request 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 23,000 0 0 0 0 23,000
Annual Time Burden (Hours) 17,250 0 0 0 0 17,250
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Cutting Redundancy
The Health History Form was updated to reflect the Executive Orders issued by the current Administration.

$100,000
No
    Yes
    Yes
No
No
No
No
Jay Olin 202 692-2507 jolin@peacecorps.gov

  Yes
 
Agency/Sub Agency RCF ID RCF Title RCF Status IC Title

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.
09/30/2025


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