View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1405-0068
ICR Reference No:
201009-1405-003
Status:
Historical Inactive
Previous ICR Reference No:
200902-1405-006
Agency/Subagency:
STATE/AFA
Agency Tracking No:
Title:
Medical History and Examination for Foreign Service
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Withdrawn and continue
Conclusion Date:
03/08/2011
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/25/2010
Terms of Clearance:
The Department of State has withdrawn this revision request and will continue to use the existing OMB-approved form.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
04/30/2012
36 Months From Approved
04/30/2012
Responses
7,234
0
7,234
Time Burden (Hours)
7,234
0
7,234
Cost Burden (Dollars)
0
0
0
Abstract:
Form DS-1622(P) and DS-1843(P) are designed to collect medical information to provide medical providers with current and adequate information to base decisions on medical suitability for a federal employee and family members for assignment abroad. DS-1622 is for Children 11 years and under. DS-1843 is for Children 12 years and older. All forms will allow medical personnel to verify that there are sufficient medical resources at a diplomatic mission abroad to maintain the health and fitness of the individual and family members within the Department of State medical program.
Authorizing Statute(s):
US Code:
22 USC 3901
Name of Law: Foreign Service Act of 1980
US Code:
22 USC 2651
Name of Law: Basic Authorities Act of 1956
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
75 FR 122
06/25/2010
30-day Notice:
Federal Register Citation:
Citation Date:
75 FR 176
09/13/2010
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Medical History and Examination for Foreign Service
DS-1843P, DS-1622P, DS-1622, DS-1843
Medical History and Examination for Foreign Service for Children 11 Years and Under
,
Pre-Employment Medical History and Examination for Foreign Service For Children 12 Years and Over
,
Pre-Employment Medical History and Examination for Foreign Service For Children 11 Years and Under
,
Medical History and Examination For Foreign Service For Individuals Age 12 and Older
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
The increase represents better estimates based on data since the last submission.
Annual Cost to Federal Government:
$364,362
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?
No
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
Agency Contact:
Anitra Collins 2026631754 collinsAS@state.gov
Common Form ICR:
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:
(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:
10/25/2010
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