Peace Corps Health History Form

Forms and Documents

Document	Type	Status	Availability
Form PC-1789 Health Status Review	Form and Instruction	Removed	Repair queued
Form PC-1789 Health History Form (PC 1789)	Form and Instruction	New	Available
Form PC-1790S Report of Medical Examination	Form and Instruction	Removed	Repair queued
PC-17.pdf	Supplementary Document	Uploaded 2012-07-12	Available
2012-1758.pdf	Supplementary Document	Uploaded 2012-07-12	Repair queued
HHF Supporting Statement 7-13-12.docx	Supporting Statement A	Uploaded 2012-07-13	Available
22 USC 2504.pdf	Supplementary Document	Uploaded 2011-06-21	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
917	Health Status Review	Form and Instruction	Removed
200891	Health History Form (PC 1789)	Form and Instruction	New
183919	Report of Medical Examination	Form and Instruction	Removed

ICR Details

OMB Control No: 0420-0510	ICR Reference No: 201201-0420-002
Status: Historical Active	Previous ICR Reference No: 201103-0420-001
Agency/Subagency: PEACE	Agency Tracking No:
Title: Peace Corps Health History Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/13/2012
	Date Received in OIRA: 01/30/2012
Terms of Clearance: Peace Corps will continue to work on streamlining the process for applications and identify improvements made during the next renewal request. Peace Corps will also explore the possibility of combining ICR No. 201201-0420-001, "Report of Physical Examination" and ICR No. 201203-0420-001 "Individual Specific Medical Evaluation Forms (16)" into this collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2014	36 Months From Approved	08/31/2014
Responses	10,000	0	14,700
Time Burden (Hours)	7,500	0	11,025
Cost Burden (Dollars)	0	0	260,000

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Abstract: All Peace Corps Volunteer applicants must undergo a physical examination prior to service during the application process to ensure good health and be able to serve without undue disruption due to health problems.

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Authorizing Statute(s): US Code: 22 USC 2504(e) Name of Law: Peace Corps Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 56821	09/14/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 4375	01/27/2012
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
Report of Medical Examination	PC-1790S	Report of Medical Examination
Health Status Review	PC-1789	Health Status Review
Health History Form (PC 1789)	PC-1789, PC-1789	Health History Form ,   Health History Form (paper version)

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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	10,000	14,700	0	-14,700	10,000	0
Annual Time Burden (Hours)	7,500	11,025	0	-11,025	7,500	0
Annual Cost Burden (Dollars)	0	260,000	0	-260,000	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Using Information Technology

Short Statement: The current process requires all Applicants to complete in its entirety a Health Status Review form (Peace Corps Form PC-1789). Under the new system, the Applicant will begin the medical part of the application process by completing the Health History Form covered by this Supporting Statement, a form which is much more comprehensive in scope than OMB form 0420-0510. The Health History Form will replace Health Status Review Form and is expected to significantly reduce the need for medical office visits and tests. The Health History Form will be completed online in an interactive process in which only questions relevant to each Applicant's medical history (based on responses to previous questions) are presented

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Annual Cost to Federal Government: $301,250

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 01/30/2012

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