[NCEZID] Statement in Support of Application for Waiver of Inadmissibility Under Immigration and Nationality Act

Forms and Documents

Document Name	Status
Form 4.422-1 Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1) Form and Instruction	Modified
Change Request Memo_4.422_July 2025.docx Justification for No Material/Nonsubstantive Change	2025-07-21
Attachment F Privacy Impact Assessment.pdf Supplementary Document	2024-01-17
Attachment D Human Research Determination.pdf Supplementary Document	2024-01-02
Supporting Statement B 2023.docx Supporting Statement B	2024-01-17
Supporting Statement A 2023.docx Supporting Statement A	2024-01-17
Attachment A3 8 CFR 212.7 Waiver of certain grounds of excludability.pdf Supplementary Document	2024-01-17
Attachment A2 42 CFR Part 34 Medical Examination of Aliens.pdf Supplementary Document	2024-01-17
Attachment A1 8 USC 1182.pdf Supplementary Document	2024-01-17

IC Document Collections

IC ID	Document Title	Status
6595	Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1) Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0006	ICR Reference No: 202507-0920-015
Status: Received in OIRA	Previous ICR Reference No: 202401-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-25-0145
Title: [NCEZID] Statement in Support of Application for Waiver of Inadmissibility Under Immigration and Nationality Act
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/23/2025

	Requested	Previously Approved
Expiration Date	03/31/2027	03/31/2027
Responses	200	200
Time Burden (Hours)	33	33
Cost Burden (Dollars)	3,260	3,260

---

Abstract: The goal of this collection is to provide CDC with adequate information to fulfill its responsibilities with regard to the processing of applications for waivers of inadmissibility on health-related grounds, specifically mental health disorders with associated harmful behaviors. The information collected is required under U.S. immigration law and regulation. CDC uses the information collected in 0920-0006 to review waiver applications for prospective immigrants and refugees to the United States. CDC assists DHS/USCIS in determining whether or not a prospective immigrant or refugee with a Class A health designation, specifically those mental health disorders with associated harmful behavior, may be admitted into the United States. Non-Substantive Change Request is submitted to make minor format changes including email and mailing addresses. There is no anticipated change to the approved burden hours.

---

Authorizing Statute(s): US Code: 8 USC 1182 Name of Law: Aliens and Nationality
   US Code: 42 USC 34 Name of Law: Public Health Service Medical Exam of Aliens
   PL: Pub.L. 212 - 7 8 Name of Law: CFR
  

Citations for New Statutory Requirements: US Code: 8 USC 1182 Name of Law: TITLE 8—ALIENS AND NATIONALITY
US Code: 42 USC Part 34 Name of Law: Public Health Service
US Code: 8 USC 212 Name of Law: Department of Homeland Security

---

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:
	88 FR 75593	11/03/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 2956	01/17/2024
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)	0920-0006, 4.422-1	STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY ,   STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY - Revised 21JUL2025

---

ICR Summary of Burden

	Total Request	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	200	200	0	0	0	0
Annual Time Burden (Hours)	33	33	0	0	0	0
Annual Cost Burden (Dollars)	3,260	3,260	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: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $72,634

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.     No

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

---

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: 07/23/2025

---