Peace Corps -- Office of Medical Services
Health Status Review (PC-1789)/Report of Medical Exam (PC-1790 S)
Report of Dental Exam (PC-1790 Dental)
OMB Approval No. 0420-0510
1. The Peace Corps Act states that “applicants for enrollment shall receive such health examinations preparatory to their service… as the president may deem necessary or appropriate.” See 22 U.S.C. 2504(e). Peace Corps has determined that all applicants “must, with reasonable accommodation, have the physical and mental capacity required of a Volunteer to perform the essential functions of the Peace Corps Volunteer assignment… without undue disruption due to health problems.” See C.F.R. 305.2(c). To ensure that Volunteers meet this medical eligibility requirement, all applicants for service must undergo physical and dental examination prior to Volunteer service “to provide the information needed for clearance, and to serve as a reference for any future Volunteer medical clearance, and to serve as a reference for any future Volunteer disability claims.” See Peace Corp Manual Section 262.2. The Health Status Review is used to review the medical history of individual applicants; the Report of Medical Exam and the Report of Dental Exam are used by the examining physician and dentist both for applicants and for currently serving Volunteers. The results of these examinations are used to ensure that applicants for Volunteer service will, with reasonable accommodation, be able to serve in the Peace Corps without jeopardizing their health.
2. The Peace Corps Office of Medical Services is responsible for the collection of applicant medical information, using the Health Status Review form (PC-1789) and the Report of Medical and Dental Exam forms (PC-1790 S and PC-1790 Dental) The applicant completes the Health Status Review and returns it to the Peace Corps. The form is then reviewed by a Peace Corps nurse and the applicant is sent a Report of Medical Exam and a Report of Dental Exam form to be completed by the applicant and the applicant’s examining physician and dentist. The Health Status Review form and the Report of Medical and Dental Exam forms are reviewed in the Peace Corps Office of Medical Services to ensure that the applicant/Volunteer has the physical and mental capacity required of a Volunteer.
3. In March 2000, the Peace Corps introduced an on-line version of the Health Status Review form. Applicants with access to the internet are now able to complete and submit the form in an electronic format. Because the Report of Medical Exam and Report of Dental Exam must be personally completed and signed by the examining physician and dentist, there are no electronic versions of these forms.
4. There is no similar information available to the Peace Corps. The Health Status Review and Report of Physical and Dental Exam forms are the only agency forms that collect this particular information concerning an applicant’s medical history and existing conditions.
5. This information does not have significant impact on small business or other small entities.
6. As described above, the Peace Corps Act requires that Volunteers receive health examinations prior to their service. The information collected is, therefore, required for consideration for Peace Corps Volunteer service. Because all medical information must be current, individuals who apply to become Peace Corps Volunteers more than once may be asked to submit multiple Health Status Review and Report of Medical and Dental Exam forms.
7. There are no special circumstances. Collection will be conducted consistent with 5 C.F.R. 1320.6 guidelines.
8. The initial Federal Register notice was published on May 25, 2007, (Volume 72, Number 101, p. 29357) for 60 days. Also available at GPO access: wais.access.gpo.gov. No comments, inquiries or responses to the notice were received.
The 30 days comment period will be published on July 16, 2007.
9. No payment or gift is provided to respondents. However, the Peace Corps does reimburse applicants who are not otherwise reimbursed by their insurance companies, for the cost of obtaining a medical exam, up to the following limits:
Females under 50 may be reimbursed up to $165
Females 50 and older may be reimbursed up to $290
Males under 50 may be reimbursed up to $125
Males 50 and older may be reimbursed up to $175
Applicants may be reimbursed up to $60 for dental exams and up to $20 for a repeat x-ray.
10. Applicants are informed that the medical information they provide will be maintained in accordance with the Privacy Act (5 U.S.C. 522 a). Specifically, applicant medical records are included in a sub-system of the Peace Corps’ Privacy Act System of Records: Volunteer Applicant and Service Records System (PC-17); other agency regulations provide for the confidential protection of records and for medical information in general.
11. Questions of a sensitive nature are asked solely from a medical perspective and the information gathered is used to determine that adequate medical and psychological support can be provided overseas. Questions of sensitive nature include whether the applicant has received or is receiving psychiatric care or psychological counseling and questions relating to alcohol and/or drug abuse or alcohol/drug related problems. The Report of Medical Exam has been revised to include a question (page 2, section IV, F) pertaining to illegal use of drugs or drug activity. Truthful responses are not used against applicants for subsequent criminal proceedings, but failure to answer truthfully could result in disqualification for Peace Corps service. Applicants are requested to authorize their respective psychiatrists or physicians to release information concerning their medical and mental health to the Peace Corps. Without the expressed authorization of the applicant, no such information is submitted to the Peace Corps for review. Medical confidentiality regulations are enforced by the Peace Corps and are guaranteed pursuant to the Privacy Act (5 U.S.C. 522a).
12. Estimates of hour burden:
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The estimate of total annual cost burden to respondents resulting from collection of information is based on an annual salary equivalent to FP 5/step 1 $39,686/year or an hourly rate of $19.01. At ½ hour times 6,000 applicants the cost burden for the Report of Medical and Dental Exam would be $57,030 each. At ¾ hour times 9,700 applicants the cost burden of the Health Status Review would be $138,298.
13. Since this is one-time data collection for applicants, there are no capital startup costs or costs for operation and maintenance of systems for respondents. Applicants whose physical exam is not covered by insurance or university infirmaries will incur the cost of any shortfall between the cost of the medical exam and the amount provided in reimbursement by the Peace Corps. For that segment of uninsured applicants, this could range from $180 to $425 depending on the age, sex and medical condition of applicant. If additional medical exams or tests are required in order to determine the applicant’s fitness for service, they are done at the applicant’s expense. Peace Corps is unable to accurately estimate how much of this expense will be borne by applicants but we have made an estimate of about $312,000 for medical exams and $252,000 for dental exams..
Responses are returned by postage paid reply mail, Peace Corps provided Federal Express mailers or electronically via the Peace Corps web site.
14. Estimated annual cost to the Federal Government:
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The cost figures are also adjusted to reflect the full costs involved with this data collection. It appears that the request previously submitted was not fully costed at that time. In addition, there have been some programmatic changes which have caused these costs to increase. There are now more staff analyzing the medical data collected due to a growing number of Peace Corps applicants. Mailing costs have also increased due to our use of Federal Express. Since the October 2001 anthrax incident, our mail has been irradiated, thus ruining incoming x-rays and weathering paper so that it is unreadable or inordinately fragile. This irradiation process has also slowed down our receipt of time sensitive mail from applicants. For this reason, we have used Federal Express to not only mail out requests for medical information in times of tight deadlines, but also for applicants to submit their medical/dental information.
15. The adjustments that appear in Items 13 and 14 of OMB Form 83-I are the result of an oversight that occurred three years ago when this collection was previously approved. At that time, the Report of Dental Exam was not included in this request although the form was in existence. We are now formally including it on this request. Also, the length of time estimated to complete the Health Status Review form has been adjusted to 45 minutes rather than the 15 minutes used previously. We feel this more accurately reflects the time required to fully complete this form. In addition, in the last three years the percentage of forms submitted electronically has increased.
The numbers previously reported in section 14 reflected costs to the government rather than to the respondents. This submission corrects the previous submission.
16. N/A This information will not be quantified or published.
17. N/A Peace Corps will display the expiration date for OMB approval of the information collection.
18. N/A Thee are no exceptions to the certification statement identified in Item 19 of OMB Form 83-1.
This collection of information does not employ statistical methods.
| File Type | application/msword |
| File Title | Peace Corps -- Office of Medical Services |
| Author | Caroline Allen |
| Last Modified By | Caroline Allen |
| File Modified | 2007-09-26 |
| File Created | 2007-09-26 |