October 17, 2007
SUPPORTING STATEMENT FOR
Form PHS-7059 Report of Medical Examination
Form PHS-7060 Report of Medical History
(Note: The following six questionnaires are online worksheets that are generated based on ‘Yes’ answers on form PHS-7060, Report of Medical History):
Form PHS-7053 Allergies Questionnaire
Form PHS-7054 Head Injury Questionnaire
Form PHS-7055 Injury Questionnaire
Form PHS-7056 Headache Questionnaire
Form PHS-7057 GYN Questionnaire
Form PHS-7061 Owestry Low Back Questionnaire
AND SUPPORTING REGULATIONS
CONTAINED IN 42 CFR 21.22 AND 21.34
Background
Pursuant to the Paperwork Reduction Act of 1995, the Office of Commissioned Corps Force Management (OCCFM), Office of Public Health and Science (OPHS), Office of the Secretary, Department of Health and Human Services (HHS), requests that the Office of Management and Budget (OMB) approve the forms listed above for use in determining the medical qualifications of applicants to the Commissioned Corps of the U.S. Public Health Service (Corps). Applicants to the Corps must meet the Corps’ medical standards in order to be considered for appointment.
OCCFM and the Office of Commissioned Corps Operations (OCCO), OPHS, Office of the Surgeon General, HHS, have redesigned -- in electronic format -- the entire Corps application and call to active duty process. In the new electronic application process, which is available (as of April 2007) at http://www.usphs.gov, information from an applicant is submitted electronically and the information is captured electronically. Additionally, the process includes a Pre-Qualification Survey in order to determine an interested individual’s eligibility for the Corps. The new electronic application and call to active duty process will greatly reduce the burden on the applicant and will streamline the entire Corps’ call to active duty process. The forms listed above (see TAB A) are to be completed online and are integral to this new electronic process. (Note: Form PHS-7059, Report of Medical Examination, must be available in paper format as it is to be completed by a health care provider during a physical examination. Also, all of the forms listed above will be available in paper format for those applicants who do not have access to a computer.)
A. Justification
Need and Legal Basis
The principal purpose for collecting the information is to permit HHS to determine medical eligibility for appointment of applicants into the Corps. The Corps is one of the seven Uniformed Services of the United States (37 U.S.C. 101(3)), and appointments in the Corps are made pursuant to 42 U.S.C. 204 et seq. and 42 CFR 21.58. Note: On July 24, 2003, the Secretary of HHS delegated the authorities necessary to administer the Corps to the Assistant Secretary for Health. This delegation may have an affect wherever the Surgeon General is cited in this document.
There are two sections of Corps regulations (see Tab B) relevant to the application process. They are 42 CFR 21.22 and 21.34. Section 42 CFR 21.22 is nonspecific in that it requires applicants to submit applications on such forms as the Surgeon General may prescribe. This nonspecific language does not require OMB approval. However, clearance for the language in 42 CFR 21.34 is sought since it requires certification by the applicant of his/her health status. Previous to this supporting statement, no additional response burden was required by this regulation because the applicant’s certification of his/her health status was performed on Department of Defense (DoD) forms DD Form 2807-1, Report of Medical History, and DD Form 2808, Report of Medical Examination, both with an HHS Privacy Act Statement, (http://dcp.psc.gov/DCPForms.asp) and the response burden was accounted for therein.
The use of the DoD forms is ongoing at this time, but OCCFM is submitting this supporting statement requesting approval for PHS forms to be used to require certification by an applicant of his/her health status. The PHS forms requiring certification and requiring OMB approval are:
PHS-7059 Report of Medical Examination
PHS-7060 Report of Medical History
The following six questionnaires are online worksheets that are generated based on ‘Yes’ answers on form PHS-7060, Report of Medical History:
PHS-7053 Allergies Questionnaire
PHS-7054 Head Injury Questionnaire
PHS-7055 Injury Questionnaire
PHS-7056 Headache Questionnaire
PHS-7057 GYN Questionnaire
PHS-7061 Owestry Low Back Questionnaire
An applicant to the Corps must submit the information requested in the application process (which includes OMB No. 0937-0025 cleared forms PHS-50, Application for Appointment as a Commissioned Officer in the U.S. Public Health Service, and PHS-1813, Reference Request for Applicants to the U.S. Public Health Service) so that a determination can be made about his/her qualifications for appointment as required by law and regulations. Recruitment and retention is a primary focus of the Corps, and efforts are directed toward recruiting entry-level health professionals and attempting to interest them in career service in the Corps.
Determining if an applicant is medically qualified for the Corps is a tedious and time consuming effort which delays the appointment of qualified individuals. The specific cause is the length of time it takes to receive information on the health status of an applicant. An individual applying for a commission with the Corps is expected to be medically qualified, currently and in the foreseeable future, to perform the duties of his/her rank and professional category in various climates and work assignments without endangering his/her health or the health of others. Currently, all candidates for appointment to the Corps must undergo a medical examination performed by a physician or healthcare provider, and be found medically qualified prior to appointment. Performing a medical examination prior to appointment greatly impacts on the Corps’ ability to swiftly appoint applicants who meet the Corps’ standards. To remedy this situation, the Corps will provide a speedier method of gathering and evaluating an applicant’s medical history.
Form PHS-7060, Report of Medical History, will replace the currently used DD Form 2807, Report of Medical History. It is intended that form PHS-7060 will be completed online by the applicant in order for OCCO’s Medical Evaluations Officer to ascertain quickly if an applicant meets the Corps’ medical standards. The Medical Evaluations Officer (a physician) has always excluded those applicants whose pre-existing medical conditions may limit their utilization, lead to excessive use of sick leave and/or excessive use of medical services, or result in increased morbidity or premature disability retirement using the previous system. This new process will enable the Corps to much more quickly disqualify or appoint an applicant.
When completing form PHS-7060, Report of Medical History, an applicant will answer questions with a ‘Yes or ‘No’ and will receive appropriate online additional questionnaires when the Corps requires more information about a particular ‘Yes’ answer. For example, if the applicant answers ‘Yes’ to the following question: “Have any allergies?”in item 13, the applicant will be presented the questions of form PHS-7053, Allergies Questionnaire. Other ‘Yes” answers will trigger questions as follows:
Item 16, Frequent, severe, or migraine headaches, ties to PHS-7056, Headache Questionnaire.
Item 19, Head injury or skull fracture, ties to PHS-7054, Head Injury Questionnaire.
Item 50, Any bone or joint problem, injuries, surgery or medical treatment, ties to PHS-7055, Injury Questionnaire.
Item 51, Steel pins, plates, or staples in any bones, ties to PHS-7055, Injury Questionnaire.
Item 52, War a bone or joint brace or support, ties to PHS-7055, Injury Questionnaire.
Item 53, Back pain or trouble, ties to PHS-7061, Owestry Low Back Questionnaire.
Item 79, Been treated for a female disorder, painful periods, or cramps, ties to PHS-7057, GYN Questionnaire.
These questionnaires probe more deeply into the applicant’s ‘Yes’ answers, and offer the Medical Evaluations Officer more necessary information in order to make a determination about the applicant’s medical condition.
Please be aware that these PHS forms are based on the following DoD forms: (https://dodmerb.tricare.osd.mil/forms.asp)
http://www.dtic.mil/whs/directives/infomgt/forms/eforms/dd2351.pdf
DD2351, DoDMERB, Report of Medical Examination;
http://www.dtic.mil/whs/directives/infomgt/forms/eforms/dd2492.pdf
DD2492, Report of Medical History;
https://dodmerb.tricare.osd.mil/docs/Allergies%20Questionnaire%2026%20Sep%2006.pdf
Allergies Questionnaire;
https://dodmerb.tricare.osd.mil/docs/Headaches%20Questionnaire%2026%20Sep%2006.pdf
Head Injury Questionnaire;
https://dodmerb.tricare.osd.mil/docs/Sports%20Injury%20Questionnaire%2026%20Sep%2006.pdf
Sports Injury Questionnaire (PHS wishes to use just ‘Injury’ Questionnaire as the title);
https://dodmerb.tricare.osd.mil/docs/Headaches%20Questionnaire%2026%20Sep%2006.pdf
Headache Questionnaire;
https://dodmerb.tricare.osd.mil/docs/GYN%20Questionnaire%2026%20Sep%2006.pdf
GYN Questionnaire; and
http://www.bodytechniques.com/pdf/Lower%20Back%20Questionnaire.pdf
Owestry Low Back Questionnaire.
Important: The DoD ‘Questionnaires’ do not contain form numbers, but OCCFM has been informed that all of the PHS ‘Questionnaires’ require individual form numbers. The Corps cannot utilize the DoD forms listed above because the DoD forms are too specific to DoD.
Form PHS-7059, Report of Medical Examination, will replace DD Form 2808, Report of Medical Examination, which the Corps presently uses. It will be in paper format and the applicant will be medically examined by a physician (MD/DO) or PA, PCNP, FNP, and once the healthcare provider completes form PHS-7059, it will be forwarded to the OCCO Medical Evaluations Officer. Applicants are cautioned on the form not to have a medical examiner/physician complete the examination and form until after the applicant receives a personnel order calling the applicant to duty with the Corps.
Information Users
If the applicant is appointed, the applicant’s health status information collected will be used for subsequent personnel actions, such as separation, and in determining eligibility for benefits.
If the applicant is not appointed, the records are retained for 2 years (4 years for an applicant to the Medical category) and then destroyed. The records are not disclosed to anyone as they are considered ‘medically confidential.’
If the information was not collected, it would not be possible to evaluate if the applicants are medically qualified for appointment to the Corps. Corps officers are expected to be medically qualified, on appointment and in the foreseeable future, to perform the duties of their rank and category in various climates and work assignments without endangering their health or the health of others.
3. Improved Information Technology
The information requested in the application process is vital for an evaluation of the applicant=s qualifications for appointment in the Corps.
A computerized applicant system permits timely tracking of applicants= records, allows specialists to generate follow-up communication, and permits officials to determine the status of each applicant at any given time during the application review process. In addition, applicants may review the status of their applications by checking information on the following Web site: http://www.usphs.gov (which is expected to change in the summer of 2007 to ecad.usphs.gov). Electronic versions (PDF fillable and Word fillable format) of forms PHS-50 and PHS-1813 are available for downloading from the following Web site: http://dcp.psc.gov/DCPForms.asp .
Original signatures are still required, thus preventing the submission of completely electronic forms.
Duplication of Similar Information
The Corps has its own requirements for appointment so there is no duplication of effort with respect to its application requirements.
Small Businesses
The information collection involves only individuals.
Less Frequent Collection
There is no other method to collect this information, and if the information is not collected, there would be no way to determine eligibility for appointment in the Corps.
Special Circumstances
Each applicant must complete the forms in the application process. The applicant completes only one application for the Corps regardless of the number of professional positions for which he/she may have an interest that are located in the HHS Operating Divisions (OPDIVs) / Staff Divisions (STAFFDIVs) as well as non-HHS organizations to which Corps officers are detailed.
Federal Register Notice/Outside Consultation
Consistent with 5 CFR 1320.8(d), a notice soliciting comments on the PHS forms listed on page 1 of this supporting statement will be published in the Federal Register. The application process pertains only to health professionals who wish to apply for appointment in the Corps. Therefore, no public comments will be sought or obtained in excess of the Federal Register notification.
9. Payment/Gift to Respondent
No payments or gifts are provided to respondents.
10. Confidentiality
Confidentiality of the data collected is provided pursuant to the Privacy Act of 1974 (5 U.S.C. 552a), and arrangements concerning the handling, storage, and disposition of medical information are explained in the Privacy Act System of Notice (09-40-0002, APHS Commissioned Corps Medical Records,@ HHS/PSC/HRS) published in the Federal Register, Vol. 63, No. 238, page 68596, December 11, 1998 (see Tab C). The methods of collecting and handling the information comply with the Privacy Act of 1974 and OMB Circular A-130, AManagement of Federal Information Resources,@ Appendix I, AFederal Agency Responsibilities for Maintaining Records About Individuals.@
11. Sensitive Questions
All medical/health related questions are sensitive and are considered ‘medically confidential.’ The records are not disclosed to anyone.
Burden Estimate (Total Hours and Wages)
Based on a sample of individuals who completed form PHS-7059, Report of Medical Examination, the average amount of time required to complete the form is 15 minutes per response. Based on a sample of individuals who completed form PHS-7060, Report of Medical History, the average amount of time required to complete the form is 15 minutes per response. All ‘Yes’ answers on PHS-7060 will trigger ‘questionnaires.’ Not all applicants will be completing all of the ‘questionnaire’ forms which are tied to PHS-7060, and some applicants will complete none of these forms. Therefore, the number of respondents for each ‘questionnaire’, i.e., PHS-7053, PHS-7054, PHS-7055, PHS-7056, PHS-7057, and PHS-7061, is approximately 20 percent; 33 percent; 70 percent; 40 percent; 15 percent; and 50 percent respectively. Based on a sample of individuals who completed forms PHS-7053, PHS-7054, PHS-7055, PHS-7056, PHS-7057, and PHS-7061, the average amount of time required to complete each form is included in 12A.
12A. Estimated Annualized Burden Hours
Form Number
|
No. of Respondents |
Response per Respondent |
Average Burden Per Response |
Total Burden Hours |
PHS-7059 |
4,000 |
1 |
15/60 |
1,000 |
PHS-7060 |
4,000 |
1 |
15/60 |
1,000 |
PHS-7053 |
800 |
1 |
6/60 |
80 |
PHS-7054 |
1,320 |
1 |
6/60 |
132 |
PHS-7055 |
2,800 |
1 |
7/60 |
327 |
PHS-7056 |
1,600 |
1 |
7/60 |
187 |
PHS-7057 |
600 |
1 |
5/60 |
50 |
PHS-7061 |
2,000 |
1 |
10/60 |
333 |
TOTAL |
|
|
|
3,109 |
12B. Annualized Burden Cost
The annualized burden cost to respondents is based on $15 wages per hour per applicant as most respondents would be recent college graduates working part-time jobs.
Form Number |
Total Burden Hours |
Hourly Wage Rate |
Total Respondent Costs |
PHS-7059 |
1,000 |
$15.00 |
$15,000 |
PHS-7060 |
1,000 |
$15.00 |
$15,000 |
PHS-7053 |
80 |
$15.00 |
$ 1,200 |
PHS-7054 |
132 |
$15.00 |
$ 1,980 |
PHS-7055 |
327 |
$15.00 |
$ 4,905 |
PHS-7056 |
187 |
$15.00 |
$ 2,805 |
PHS-7057 |
50 |
$15.00 |
$ 750 |
PHS-7061 |
333 |
$15.00 |
$ 4,995 |
TOTAL |
|
|
$46,635 |
Capital Costs (Maintenance of Capital Costs)
The only costs to the respondents is the time required to complete the forms online.
Cost to the Federal Government
On average, approximately 20 minutes of staff time by two personnel specialists (average grade GS-9/Step 6 ($83,480 average of both salaries plus overhead) are required to process applications. At approximately $40 per hour, the cost of processing is approximately $13.38 for each application for 4,000 yearly applications or $53,513.
On average, approximately 25 minutes of professional staff time is required to review each online application. At $247,000 (salary plus overhead), the cost of one professional personnel reviewing applications is $49 per application for 4,000 yearly applications or $198,000.
Applicants are to complete the application process online; however about 50 printed packets costing $200 will be prepared. Thus, annual cost to the Federal Government for processing applications is estimated to be $ 251,713.
Program or Burden Changes
This is a new collection.
Publication and Tabulation Dates
The data collected will not be published for statistical use.
17. Expiration Date
This request is for a 3-year approval and the date of expiration of OMB approval will be displayed on each form.
18. Certification Statement
There are no exceptions.
B. Collection of Information Employing Statistical Methods
Not applicable. The information collected will not be analyzed by employing statistical methodology.
Dated: October 17, 2007
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR |
| Last Modified By | sxp1 |
| File Modified | 2007-10-17 |
| File Created | 2007-10-17 |