View Information Collection Request (ICR) Package

OMB Control No: 0990-0324	ICR Reference No: 202006-0990-002
Status: Historical Active	Previous ICR Reference No: 201612-0990-001
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Report of Medical History/Examination
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/03/2020
	Date Received in OIRA: 07/27/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2023	36 Months From Approved	09/30/2020
Responses	1,000	0	14,120
Time Burden (Hours)	1,000	0	4,109
Cost Burden (Dollars)	0	0	0

Abstract: 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.

Authorizing Statute(s): US Code: 37 USC 101 Name of Law: Uniformed Services of the United States
US Code: 42 USC 204 Name of Law: Corps

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:
	85 FR 20281	04/10/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 44310	07/22/2020
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
Allergies Questionnaire	PHS-7053
GYN Questionnaire	PHS-7057
Head Injury Questionnaire	PHS-7054
Headache Questionnaire	PHS-7056
Injury Questionnaire	PHS-7055
Qwestry Low Back Questionnaire	PHS-7061
Report of Dental Examination	PHS-6355
Report of Medical Examination	PHS-6379

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	1,000	14,120	-13,120
Annual Time Burden (Hours)	1,000	4,109	-3,109
Annual Cost Burden (Dollars)	0	0	0

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: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: 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)

Annual Cost to Federal Government: $50,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

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? No

Agency Contact: Sherette Funn-Coleman

View ICR - OIRA Conclusion