Supporting Statement 0420-0510

Peace Corps -- Office of Medical Services
Health Status Review (PC-1789)/Report of Medical Exam (PC-1790 S)
OMB Approval No. 0420-0510

SUPPORTING STATEMENT
Section A. Justification
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 262.4. 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), the Report of Medical
Exam (PC-1790 S) and the Dental Exam (PC-1790). 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 agency’s notice was published in the Federal Register on March 28, 2011, 76 FR 17164.
No public comments were received during the 60-day period.
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. 522a). 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.

a. Estimated number of respondents
b. Estimated average burden per
response
c. Frequency of response
d. Annual reporting burden

Health
Status
Review
(PC 1789)
9,700
45 minutes

Report of
Medical
Evaluation
(PC 1790 S)
5,000
45 minutes

One time
7,275

One time
3,750

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 the cost to be approximately $266,034 in medical exam fees
($175,546 for Health Status Review and $90,488 for the Report of Medical Evaluation).
14. Estimated annual cost to the Federal Government:
Responses are returned by postage paid reply mail, Peace Corps provided Federal Express
mailers or electronically via the Peace Corps web site.

PC-1789
Health Status
Review
Printing
Mailing
Analyzing Information*
Physician's Fees

$25,815
$2,081
$57,030
n/a

PC-1790 S
Report of
Medical
Exam
$13,320
$21,600
$138,298
$471,083

Total cost to the Federal Government

$84,926

$644,301

*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 5,000 applicants the cost burden for the Report of Medical $57,030 each. At ¾
hour times 9,700 applicants the cost burden of the Health Status Review would be $138,298.

15. The adjustments that appear in Items 13 and 14 of OMB Form 83-I are the result of the
removal of the Report of Dental Exam form. Additionally, the number of applicants who
complete the medical process has to been change to reflect a more accurate number.
16. Not applicable. This information will not be quantified or published.
17. Not applicable. Peace Corps will display the expiration date for OMB approval of the
information collection.
18. Not applicable. There are no exceptions to the certification statement identified in Item 19 of
OMB Form 83-1.

Section B. Collection of Information Employing Statistical Methods
This collection of information does not employ statistical methods.