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60-Day Notice of Proposed Information Collection: DS 1843 and 1622, Medical History and Examination for Foreign Service, OMB 1405-0068

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Notice of request for public comments.


The Department of State is seeking Office of Management and Budget (OMB) approval for the information collection described below. The purpose of this notice is to allow 60 days for public comment in the Federal Register preceding submission to OMB. We are conducting this process in accordance with the Paperwork Reduction Act of 1995.

Title of Information Collection: Medical History and Examination for Foreign Service.

OMB Control Number: 1405-0068.

Type of Request: Extension of Currently Approved Collection.

Originating Office: Office of Medical Services, M/MED/EX.

Form Number: DS 1843 and 1622.

Respondents: Family members of Foreign Service Officers and Federal employees stationed abroad. (Note: For purposes of the Paperwork Reduction Act, employees of the U.S. Government are not counted as respondents.)

Estimated Number of Respondents: 9,800.

Estimated Number of Responses: 9,800.

Average Hours Per Response: 1.

Total Estimated Burden: 9,800 hours.

Frequency: On occasion.

Obligation to Respond: Required to obtain a benefit.


The Department will accept comments from the public up to 60 days from May 25, 2005.


You may submit comments by any of the following methods:

  • E-mail: You must include the DS form number, information collection title, and OMB control number in the subject line of your message.
  • Mail (paper, disk, or CD-ROM submissions): Department of State, Office of Medical Services, SA-1 Room L-101, 2401 E St., NW., Washington DC 20052-0101.
  • Fax: 202-663-1661.
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Direct requests for additional information regarding the collection listed in this notice, including requests for copies of the proposed information collection and supporting documents, to Susan Willig, Department of State, Office of Medical Services, SA-1 Room L101, 2401 E St., NW., Washington DC 20052-0101, who may be reached on 202-663-1754 or at

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We are soliciting public comments to permit the Department to:

  • Evaluate whether the proposed information collection is necessary for the proper performance of our functions.
  • Evaluate the accuracy of our estimate of the burden of the proposed collection, including the validity of the methodology and assumptions used.
  • Enhance the quality, utility, and clarity of the information to be collected.
  • Minimize the reporting burden on those who are to respond, including the use of automated collection techniques or other forms of technology.

Abstract of proposed collection: Form DS-1843 and 1622 are designed to collect medical information to provide medical providers with current and adequate information to base decisions on whether a federal employee and family members will have sufficient medical resources at a diplomatic mission abroad to maintain the health and fitness of the individual and family members.

Methodology: The information collected will be collected through the use of an electronic forms engine or by hand written submission using a pre-printed form.

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Dated: May 10, 2005.

Maria C. Melchiorre,

Administrative Officer, Office of Medical Services, Department of State.

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[FR Doc. 05-10454 Filed 5-24-05; 8:45 am]