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OMB Control No: 1405-0068	ICR Reference No: 202603-1405-001
Status: Received in OIRA	Previous ICR Reference No: 202312-1405-003
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	Date Submitted to OIRA: 03/11/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2026
Responses	4,600	2,561
Time Burden (Hours)	4,600	2,561
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate
Annual Number of Responses	4,600	2,561	-522	2,561
Annual Time Burden (Hours)	4,600	2,561	-522	2,561
Annual Cost Burden (Dollars)	0	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: Changing Forms

Short Statement: These forms require a pre-assignment and pre-employment applicant, and their eligible family members, to provide information regarding chronic medical conditions, mental health status, and past mental health treatment. Although not routinely discussed, except with a person’s health care provider, these questions are necessary to gauge the individual and family members’ ability to be assigned to hardship posts, or posts where medical resources are scarce. These forms also might include information regarding special educational needs that a dependent child may have.

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: Claire Whitacre 771 205-9036

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