Information Collection Request

Medical History and Examination

ICR 202301-1405-006 · OMB 1405-0068 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1405-0068 can be found here:

Forms and Documents

Document Name	Status
Form DS-1622 Medical History and Examination Form and Instruction	Modified
1405-0068 30-day Published.pdf Supplementary Document	2023-01-26
11917_PublishedFR_11-14-2022.pdf Supplementary Document	2023-01-26
Legal Authorities 1405-0068.docx Supplementary Document	2023-01-26
30 day Updated Supporting Statement 1405-0068.docx Supporting Statement A	2023-01-26

IC Document Collections

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

ICR Details

Status	Received in OIRA
Agency/Subagency	STATE/AFA
OMB Control No	1405-0068
Type of Information Collection	Revision of a currently approved collection
Previous ICR Reference No	202008-1405-002
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31