Peace Corps -- Office of Medical Services
Report of Dental Exam (PC-1790 Dental)
OMB Control No. 0420-0546
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. Applicants access the Dental Examination form via a secure online portal. Applicants will download the form for their dentist to complete. The Dental Exam form must be personally completed and signed by the examining dentist. The completed form can be scanned and uploaded back into the Applicant’s secure Peace Corps online portal or it can be faxed or mailed to the Peace Corps Office of Medical Services. Applicant’s dentist does not have access to the Applicant’s secure Peace Corps online portal therefore unable to complete and sign the Dental Exam form electronically.
4. There is no similar information available to the Peace Corps. The Report of Dental Exam form is the only agency form that collects this particular information concerning an applicant’s dental 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 August 4, 2014, 79 FR 45226. No public comments were received during the 60-day period. The 30-Day notice was published October 14, 2014, 79 FR 61671.
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. 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). Applicants also sign an Authorization permitting the use and disclosure of medical information within the Peace Corps to Peace Corps staff with a specific need to know the information.
11. No questions of a sensitive nature are asked.
12. Estimates of the hour burden:
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Dental Exam Form |
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5400 |
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45 minutes |
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One time |
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4050 |
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 $864,000 for the Report of Dental Evaluation. We calculate this figure based on an estimated cost of $160.00 per applicant times 5400 applicants per year. Cost per applicant is $220.00 ($70.00 for the dental examination and $150.00 for the associated dental x-rays, less the Peace Corps Cost Share reimbursement of $60.00). These cost estimates do not take into account applicants with health insurance and who do not request cost share reimbursement.
14. Estimated annual cost to the Federal Government:
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Responses are returned by postage paid reply mail, Peace Corps provided Federal Express mailers or electronically via the Peace Corps web site.
15. We missed the renewal deadline. The Dental Examination form is currently in use with an expired OMB approval date.
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.
This collection of information does not employ statistical methods.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Peace Corps -- Office of Medical Services |
| Author | Caroline Allen |
| File Modified | 0000-00-00 |
| File Created | 2021-01-26 |