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PC 1789 Health History Form 2025
Peace Corps Health History Form
OMB: 0420-0510
IC ID: 277807
OMB.report
PEACE
OMB 0420-0510
ICR 202509-0420-001
IC 277807
( )
Documents and Forms
Document Name
Document Type
Form PC-1789
PC 1789 Health History Form 2025
Form and Instruction
PC-1789 Health History Form
PC 1789 Current HHF as of 9-26-2025.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
PC 1789 Health History Form 2025
Agency IC Tracking Number:
PC-1789
Is this a Common Form?
Yes
IC Status:
New
Obligation to Respond:
Voluntary
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
PC-1789
Health History Form
PC 1789 Current HHF as of 9-26-2025.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
International Affairs and Commerce
Subfunction:
International Development and Humanitarian Aid
Privacy Act System of Records
Title:
PC-17 Volunteer Applicant and Service Records System
FR Citation:
79 FR 41599
Number of Respondents:
23,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
99 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
23,000
0
23,000
0
0
0
Annual IC Time Burden (Hours)
17,250
0
17,250
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.