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:
202301-1405-006
Status:
Historical Active
Previous ICR Reference No:
202008-1405-002
Agency/Subagency:
STATE/AFA
Agency Tracking No:
Title:
Medical History and Examination
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
04/10/2023
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/26/2023
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
04/30/2026
36 Months From Approved
10/31/2023
Responses
2,561
0
2,039
Time Burden (Hours)
2,561
0
2,039
Cost Burden (Dollars)
0
0
0
Abstract:
The documents are necessary to the Foreign Service Act of 1980, as amended (22 U.S.C. 4084, 3901, 3984). They are used to document results of the Foreign Service Medical History and Examination for preemployment decisions. Every person who has been given a conditional offer of employment for Foreign Service with the Department of State (DOS) must be healthy and able to travel to post of assignment worldwide. Those who are not able to travel and serve world wide are not hired. Without these forms, DOS would not have a consistent and fair means to document that each new employee meets the medial criteria for world wide employment in the Foreign Service and family health care needs be met at overseas posts.
Authorizing Statute(s):
PL:
Pub.L. 110 - 233 122
Name of Law: Genetic Information Nondiscrimination Act of 2008
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:
87 FR 68222
11/14/2022
30-day Notice:
Federal Register Citation:
Citation Date:
88 FR 4279
01/24/2023
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
DS-1622, DS-1843
Medical History and Examination for Children Age 11 and Younger
,
Medical History and Examination for Individuals Age 12 and Older
ICR Summary of Burden
Total Approved
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
2,561
2,039
0
522
0
0
Annual Time Burden (Hours)
2,561
2,039
0
522
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Please see supporting statement.
Annual Cost to Federal Government:
$30,748
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:
Michelle Yelland 202 663-1657
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:
01/26/2023
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