Peace Corps Volunteers Long Term Health Outcomes Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2155 Long Term Health Outcome Survey	Form	New	Available
Attachment 2_Protocol_LToutcomes.docx	Supplementary Document	Uploaded 2016-06-03	Available
Public Health Service Act (42 USC 241).pdf	Supplementary Document	Uploaded 2015-10-20	Available
Protocol_Long Term Health Outcomes Survey_2015-6-15.pdf	Supplementary Document	Uploaded 2015-10-20	Available
Long Term Health Survey_Supporting Statement_Section B.docx	Supporting Statement B	Uploaded 2015-10-20	Available
Long Term Health Survey_Supporting Statement (2).docx	Supporting Statement A	Uploaded 2016-06-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
218647	Long Term Health Outcome Survey	Form	New

ICR Details

OMB Control No: 0420-0557	ICR Reference No: 201510-0420-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: PEACE	Agency Tracking No:
Title: Peace Corps Volunteers Long Term Health Outcomes Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/03/2016
	Date Received in OIRA: 10/21/2015
Terms of Clearance: This matched cohort design is approved for the purposes of generating hypotheses about the risks associated with long-term malaria prophylaxis. The sampling frame and prior response rates from this population during similar studies prevent the results of this study from being used to generate chronic disease prevalence estimates for Peace Corps volunteers or to compare such rates with other sub-populations.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2019	36 Months From Approved
Responses	11,196	0	0
Time Burden (Hours)	2,799	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The information in the Peace Corps Volunteers Long Term Health Outcomes survey will be compiled and analyzed by the Malaria Branch of the Center for Global Health at the Centers for Disease Control and Prevention (CDC) in conjunction with the Peace Corps Office of Health Services, Epidemiology and Surveillance Unit to describe the long term health outcomes of Peace Corps Volunteer service.

---

Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service 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:
	80 FR 42132	07/16/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 63847	10/21/2015
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Long Term Health Outcome Survey	2155	RPCV Long Term Health Outcomes Survey

---

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	11,196	0	0	11,196	0	0
Annual Time Burden (Hours)	2,799	0	0	2,799	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: This is a new information collection. No changes or adjustments have been made at this time.

---

Annual Cost to Federal Government: $10,987

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 10/21/2015

---