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60-Day Notice of Proposed Information Collection: Medical History and Examination for Foreign Service

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Notice of request for public comment.


The Department of State is seeking Office of Management and Budget (OMB) approval for the information collection described below. In accordance with the Paperwork Reduction Act of 1995, we are requesting comments on this collection from all interested individuals and organizations. The purpose of this notice is to allow 60 days for public comment preceding submission of the collection to OMB.


The Department will accept comments from the public up to May 26, 2017.


You may submit comments by any of the following methods:

  • Web: Persons with access to the Internet may comment on this notice by going to You can Start Printed Page 15267search for the document by entering “Docket Number: DOS-2016-0073” in the Search field. Then click the “Comment Now” button and complete the comment form.
  • Email:
  • Regular Mail: Send written comments to: Office of Medical Clearances, SA-15 Room 400, 1800 North Kent St., Rosslyn, VA. 22209.
  • Fax: 703-875-4850.

You must include the DS form number (if applicable), information collection title, and the 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 collection instrument and supporting documents, to Joan F. Grew who may be reached on 703-875-5412 or at

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  • Title of Information Collection: Medical History and Examination for Foreign Service.
  • OMB Control Number: 1405-0068.
  • Type of Request: Revision of a Currently Approved Collection.
  • Originating Office: Bureau of Medical Services—Medical Clearances Department.
  • Form Numbers: DS-1843 and DS-1622.
  • Respondents: Foreign Service applicants or employees or eligible family members.
  • Estimated Number of Respondents: 7,814.
  • Estimated Number of Responses: 7,814.
  • Average Time per Response: 1 hour.
  • Total Estimated Burden Time: 7,814 hours.
  • Frequency: Upon Entry to Foreign Service and then intermittent, as needed.
  • Obligation To Respond: Required to Obtain or Retain a Benefit.

We are soliciting public comments to permit the Department to:

  • Evaluate whether the proposed information collection is necessary for the proper functions of the Department.
  • Evaluate the accuracy of our estimate of the time and cost burden for this 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 information technology.

Please note that comments submitted in response to this Notice are public record. Before including any detailed personal information, you should be aware that your comments as submitted, including your personal information, will be available for public review.

Abstract of Proposed Collection

Forms DS-1843 and DS-1622 collect medical history, lab tests and physical examination for employees and family members for the Foreign Affairs agencies, to include State, USAID, Foreign Commercial Service, Foreign Agricultural Service and Broadcasting Board of Governors. Forms DS-1843 and DS-1622 are designed to collect sufficient and current medical information on the individual in order for a medical provider to make a medical clearance determination for initial appointment to the Foreign Service. They are also used to determine whether a Foreign Service applicant, employee, or eligible family member will have appropriate medical and/or educational resources at a diplomatic mission/host country abroad to maintain the health and safety of the individual or family member.


The information 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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Behzad Shahbazian,

Director of Clinical Services, Bureau of Medical Services, Department of State.

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[FR Doc. 2017-05950 Filed 3-24-17; 8:45 am]