Medical History and Examination

Forms and Documents

Document Name	Status
Form DS-1622 Medical History and Examination Form and Instruction	Modified
Final - Supporting Statement 1405-0068 10-19.docx Supporting Statement A	2020-10-19
Legal Authorities 1405-0068.docx Supplementary Document	2020-08-13

IC Document Collections

IC ID	Document Title	Status
14884	Medical History and Examination Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0068	ICR Reference No: 202008-1405-002
Status: Active	Previous ICR Reference No: 201706-1405-001
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: 10/19/2020
	Date Received in OIRA: 08/13/2020
Terms of Clearance: Agency made minor clarifications to the supporting statement.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2023	36 Months From Approved	10/31/2020
Responses	2,039	0	7,814
Time Burden (Hours)	2,039	0	7,814
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): PL: Pub.L. 110 - 233 122 Name of Law: Genetic Information Nondiscrimination Act of 2008
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 28134	05/12/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 47284	08/04/2020
Did the Agency receive public comments on this ICR? No

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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

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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	2,039	7,814	0	-5,775	0	0
Annual Time Burden (Hours)	2,039	7,814	0	-5,775	0	0
Annual Cost Burden (Dollars)	0	0	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: Miscellaneous Actions

Short Statement: The 2,039 DS-1843/1622 respondents represent approximately a 74% decrease from the previous Paperwork Reduction Act submission.

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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

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Common Form ICR:  No

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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: 08/13/2020

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