Dental - Supporting Statement 0420-0510

Peace Corps -- Office of Medical Services

Report of Dental Exam (PC-1790 Dental)

OMB Control No. 0420-xxxx

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 22 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.

2. The Peace Corps Office of Medical Services is responsible for the collection of applicant dental information, using the Report of Dental Exam “Dental Exam” form. The Dental Exam form is completed by the applicant and the applicant’s examining dentist. The Dental Exam form is used by the examining dentist both for applicants and for currently serving Volunteers. The results of the 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.

3. The Dental Exam form must be personally completed and signed by the examining 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. 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 additional 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. 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 the hour burden:

	Dental Exam Form
a. Estimated number of respondents	5,000
b. Estimated average burden per response	45 minutes
c. Frequency of response	One time
d. Annual reporting burden	3,750

13. Peace Corps is unable to accurately estimate how much of this expense will be borne by applicants but we estimate the cost to be approximately $90,488 for the Report of Dental Evaluation.

14. Estimated annual cost to the Federal Government:

Printing	$3,300
Mailing	$21,600
Analyzing Information	$78,678
Physician's Fees	$180,000
Total cost to the Federal Government	$283,578

Responses are returned by postage paid reply mail, Peace Corps provided Federal Express mailers or electronically via the Peace Corps web site.

15. The number of applicants who complete the process has been changed 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.