Individual Specific Medical Evaluation Forms (16)

Forms and Documents

Document	Type	Status	Availability
Form PC-OMS-116 Prescription for Eyeglassess	Form and Instruction	New	Available
Form PC-262-10 Insulin Dependent Diabetic Supplement Documentation Form	Form and Instruction	New	Repair queued
Form PC-262-12 Reactive Tuberculin Test Evaluation Form	Form and Instruction	New	Repair queued
Form PC-262-7 ECG Form	Form and Instruction	New	Repair queued
Form PC-262-9 Colon Cancer Screening Form	Form and Instruction	New	Available
Form PC-262-11 Pap Screening Form	Form and Instruction	New	Repair queued
Form TG-355-2 Mammogram Form	Form and Instruction	New	Available
Form PC-262-6 Alcohol/Substance Abuse Current Evaluation	Form and Instruction	New	Repair queued
Form TG-510-2 Mental Health Current Evaluation	Form and Instruction	New	Repair queued
Form PC-262-8 Eating Disorder Treatment Summary Form	Form and Instruction	New	Repair queued
Form TG-510-3 Mental Health Treatment Summary Form	Form and Instruction	New	Available
Form PC-262-4 Low Body Mass Index Evaluation Form	Form and Instruction	New	Repair queued
Form PC-262-5 Disease Diagnosis Form	Form and Instruction	New	Available
Form PC-262-3 Diabetes Diagnosis Form	Form and Instruction	New	Repair queued
Form PC-262-2 Asthma Evaluation Form	Form and Instruction	New	Available
Form PC-262-1 Allergy Treatment Form	Form and Instruction	New	Repair queued
PC-17.pdf	Supplementary Document	Uploaded 2012-07-12	Available
Indivdual Specific Medical Eval Forms (16) 07132012.docx	Supporting Statement A	Uploaded 2012-07-13	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
201724	Prescription for Eyeglassess	Form and Instruction	New
201719	Insulin Dependent Diabetic Supplement Documentation Form	Form and Instruction	New
201718	Reactive Tuberculin Test Evaluation Form	Form and Instruction	New
201717	ECG Form	Form and Instruction	New
201716	Colon Cancer Screening Form	Form and Instruction	New
201715	Pap Screening Form	Form and Instruction	New
201714	Mammogram Form	Form and Instruction	New
201710	Alcohol/Substance Abuse Current Evaluation	Form and Instruction	New
201709	Mental Health Current Evaluation	Form and Instruction	New
201708	Eating Disorder Treatment Summary Form	Form and Instruction	New
201707	Mental Health Treatment Summary Form	Form and Instruction	New
201686	Low Body Mass Index Evaluation Form	Form and Instruction	New
201685	Disease Diagnosis Form	Form and Instruction	New
201684	Diabetes Diagnosis Form	Form and Instruction	New
201683	Asthma Evaluation Form	Form and Instruction	New
201682	Allergy Treatment Form	Form and Instruction	New

ICR Details

OMB Control No: 0420-0550	ICR Reference No: 201203-0420-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: PEACE	Agency Tracking No:
Title: Individual Specific Medical Evaluation Forms (16)
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/13/2012
	Date Received in OIRA: 03/27/2012
Terms of Clearance: Peace Corps will continue to work on streamlining the process for applications and identify improvements made during any future renewal requests. Peace Corps will also explore the possibility of combining this ICR and ICR No. 201201-0420-001 with OMB Control Number 0420-0510.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2014	36 Months From Approved
Responses	16,528	0	0
Time Burden (Hours)	31,951	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The 16 forms listed may be sent to an individual Applicant at one of the following times in the medical review process: (1) after the Applicant completes the Health History Form and receives a nomination; (2) after a Peace Corps nurse reviews the Applicant's Health History Form and any completed forms previously requested; or (3) at the time of the Applicant's physical examination. The results of the physical examination and the information contained in the specific evaluation forms covered by this Supporting Statement will be used to make an individualized determination as to whether an Applicant for Volunteer service will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems.

---

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

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 3013	01/20/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 18273	03/27/2012
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 16

IC Title	Form No.	Form Name
Prescription for Eyeglassess	PC-OMS-116	Prescriptin Eyeglassess Form
Asthma Evaluation Form	PC-262-2	Asthma Evaluation Form
Diabetes Diagnosis Form	PC-262-3	Diabetes Diagnosis Form
Disease Diagnosis Form	PC-262-5	Disease Diagnosis Evaluation Form
Low Body Mass Index Evaluation Form	PC-262-4	Low Body Mass Index Evaluation Form
Mental Health Treatment Summary Form	TG-510-3	Mental Health Treatment Summary
Allergy Treatment Form	PC-262-1	Allergy Treatment Form
Alcohol/Substance Abuse Current Evaluation	PC-262-6	Alcohol/Substance Abuse Current Evaluation Form
Mammogram Form	TG-355-2	Mammogram Form
Pap Screening Form	PC-262-11	Pap Screening Form
ECG Form	PC-262-7	ECG Form
Reactive Tuberculin Test Evaluation Form	PC-262-12	Reactive Tuberculin Test Evaluation Form
Insulin Dependent Diabetic Supplement Documentation Form	PC-262-10	Insulin Depended Diabetic Supplemental Form
Eating Disorder Treatment Summary Form	PC-262-8	Eating Disorder Treatment Summary Form
Mental Health Current Evaluation	TG-510-2	Mental Health Current Evaluation Form
Colon Cancer Screening Form	PC-262-9	Colon Cancer Screening Form

---

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	16,528	0	0	16,528	0	0
Annual Time Burden (Hours)	31,951	0	0	31,951	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: All questions contained in these forms were previously part of a separate form under a separate OMB control number that contained other questions and requests for information outside of the scope of these new forms. Applicants originally had to respond to these questions even if they did not have a history of the conditions covered by these forms. These questions have been separated out and included in these particular forms which will be provided only to Applicants who have stated a history of these conditions in the Health History Form.

---

Annual Cost to Federal Government: $177,307

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

---

Common Form ICR:  No

---

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: 03/27/2012

---