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60-Day Notice of Proposed Information Collection: Form DS-1622, DS-1843, DS-1622P, and DS-1843P: 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: Revision of Currently Approved Collection.
  • Originating Office: Office of Medical Services, M/MED/C/MC.
  • Form Number: DS-1622, DS-1843, DS-1622P, and DS-1843P.
  • Respondents: Foreign Service Officers, State Department Employees, Other Government Employees and Family Members.
  • Estimated Number of Respondents: 7,500 per year.
  • Estimated Number of Responses: 7,500 per year.
  • Average Hours per Response: 1.0 hours per response.
  • Total Estimated Burden: 7,500 hours.
  • Frequency: On occasion.
  • Obligation to Respond: Mandatory.


The Department will accept comments up to August 24, 2010.


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 (Attn: Susan Willig), 2401 E St., NW., Washington, DC 20522-0101.
  • Fax: 202-663-1934.
  • If you have access to the Internet, you can view this notice and provide comments by going to​search/​Regs/​home.html#home.

You must include the DS form number (if applicable), information collection title, and OMB control number in any correspondence.

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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 Columbia Plaza Room L101 (Attn: Susan Willig), 2401 E St., NW., Washington DC, 20052-0101, who may be reached on 202-663-1754 or

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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-1622(P) and DS-1843(P) are 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. DS-1622 is for Children 11 years and under. DS-1843 is for Children 12 years and older. All 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 Department of State medical program.

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: June 22, 2010.

Sharon Ludan,

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

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[FR Doc. 2010-15475 Filed 6-24-10; 8:45 am]