APPLICANT MEDICAL PRESCREENING FORM, AMERICORPS*NATIONAL CIVILIAN COMMUNITY CORPS

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
149236	APPLICANT MEDICAL PRESCREENING FORM, AMERICORPS*NATIONAL CIVILIAN COMMUNITY CORPS	Migrated

ICR Details

OMB Control No: 3045-0025	ICR Reference No: 199504-3045-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: CNCS	Agency Tracking No:
Title: APPLICANT MEDICAL PRESCREENING FORM, AMERICORPS*NATIONAL CIVILIAN COMMUNITY CORPS
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Expedited
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/09/1995
	Date Received in OIRA: 04/14/1995
Terms of Clearance: Approved as amended by CNCS' memoranda to OMB of 5/4/95 and 5/9/95. This form will be used to collect medical information from all NCCC corpsmembers following their selection, and to inform CNCS about any accomodations that may be necessary for corpsmembers with disabilities. The form is completed prior to the physical examination that is required of all corpsmembers, and this approval negates the need for additional general medical questions. Failure to complete the form may result in disqualification from further processing, pending the conclusions of the medical and program personnel regarding medical conditions and related concerns on a case-by-case basis.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/1998	05/31/1998
Responses	2,002	0	0
Time Burden (Hours)	1,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: THE APPLICANT MEDICAL PRESCREENING FORM WILL PROVIDE NECESSARY INFORMATION TO ASSIST IN THE SELECTION PROCESS OF AMERICORPS*NCCC MEMBERS SO THAT WE DO NOT PLACE AN INDIVIDUAL INTO THE PROGRAM WHOSE PREEXISTING CONDITION OR MEDICAL HISTORY MAY ENDANGER THEIR OWN HEALTH OR SAFETY OR THAT OF ANOTHER. ADDITIONALLY, THIS FORM WILL ALLOW US TO MAKE ACCOMMODATIONS FOR CORPS MEMBERS WITH SPECIAL NEEDS. RESPONDENTS WILL BE INDIVIDUALS 17-24 YEARS OF AGE APPLYING TO BE AMERICORPS*NCCC MEMBERS.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
APPLICANT MEDICAL PRESCREENING FORM, AMERICORPS*NATIONAL CIVILIAN COMMUNITY CORPS

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ICR Summary of Burden

	Total Approved	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	2,002	0	0	2,002	0	0
Annual Time Burden (Hours)	1,000	0	0	1,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 04/14/1995

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