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

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Notice of request for public comment and submission to OMB of proposed collection of information.


The Department of State has submitted the following information Start Printed Page 6943collection request to the Office of Management and Budget (OMB) for approval 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: Revision of Currently Approved Collection.
  • Originating Office: Office of Medical Support, M/MED/C/MC.
  • Form Number: DS-1622 and DS-1843.
  • Respondents: Foreign Service Officers, State Department Employees, Other. Government Employees and Family Members.
  • Estimated Number of Respondents: 7,234 per year.
  • Estimated Number of Responses: 7,234 per year.
  • Average Hours per Response: 1.0 hours per response.
  • Total Estimated Burden: 7,234 hours.
  • Frequency: On Occasion.
  • Obligation to Respond: Mandatory.


Submit comments to the Office of Management and Budget (OMB) for up to 30 days from February 11, 2009.


Direct comments and questions to Katherine Astrich, the Department of State Desk Officer in the Office of Information and Regulatory Affairs at the Office of Management and Budget (OMB), who may be reached at 202-395-4718. 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): Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW., Washington, DC 20503.
  • Fax: 202-395-6974.
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You may obtain copies of the proposed information collection and supporting documents from Anitra Collins, Room L213, 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 to properly perform 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:

Forms DS-1622 and DS-1843 is designed to collect medical information to provide medical providers with current and adequate information to base decisions on medical suitability for a federal employee and family members for assignment abroad. Both forms will allow medical personnel to verify that there are sufficient medical resources at a diplomatic mission abroad to maintain the health and fitness of the individual and family members within the State Department medical program.


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: January 14, 2009.

Sharon Ludan,

Executive Director, Office of Medical Services, Department of State.

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[FR Doc. E9-2931 Filed 2-10-09; 8:45 am]