Individual Specific Medical Evaluation Forms (16)

ICR 201401-0420-006

OMB: 0420-0550

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Supporting Statement A
2014-02-10
Supplementary Document
2012-07-12
ICR Details
0420-0550 201401-0420-006
Historical Active 201203-0420-001
PEACE
Individual Specific Medical Evaluation Forms (16)
Extension without change of a currently approved collection   No
Regular
Approved without change 03/18/2014
Retrieve Notice of Action (NOA) 02/10/2014
  Inventory as of this Action Requested Previously Approved
03/31/2017 36 Months From Approved 03/31/2014
16,528 0 16,528
31,951 0 31,951
0 0 0

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 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.

US Code: 22 USC 2504 Name of Law: Peace Corps Act
  
None

Not associated with rulemaking

  78 FR 72125 12/02/2013
79 FR 7713 02/10/2014
No

  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 16,528 0 0 0 0
Annual Time Burden (Hours) 31,951 31,951 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$177,307
No
No
No
No
No
Uncollected
Denora Miller 202 692-1236 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/10/2014


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