Report of Dental Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form PC-OMS-1790 Dental Report of Dental Evaluation	Form and Instruction	Modified	Available
Dental-SupportingStatement 0420-0546 Final Version.docx	Supporting Statement A	Uploaded 2015-02-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198187	Report of Dental Evaluation	Form and Instruction	Modified

ICR Details

OMB Control No: 0420-0546	ICR Reference No: 201410-0420-002
Status: Historical Active	Previous ICR Reference No: 201106-0420-002
Agency/Subagency: PEACE	Agency Tracking No:
Title: Report of Dental Evaluation
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/25/2015
	Date Received in OIRA: 10/14/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2018	36 Months From Approved
Responses	5,400	0	0
Time Burden (Hours)	4,050	0	0
Cost Burden (Dollars)	864,000	0	0

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Abstract: The Peace Corps Office of Medical Services is responsible for the collection of applicant dental information, using the Report of Dental Exam form. The Dental Exam form is completed by the applicant and the applicant's examining dentist. 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.

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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:
	79 FR 45226	08/04/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 61671	10/14/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Report of Dental Evaluation	PC-OMS-1790 Dental S	Report of Dental Evaluation

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ICR Summary of Burden

table that charts list 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	5,400	0	0	400	0	5,000
Annual Time Burden (Hours)	4,050	0	0	300	0	3,750
Annual Cost Burden (Dollars)	864,000	0	0	864,000	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: Change made at the discretion of Agency to reflect a more accurate reflection of number of respondents.

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Annual Cost to Federal Government: $390,536

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]? Yes

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:  Yes

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

table that charts list of RCF

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

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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: 10/14/2014

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