Justification - 30 Day Notice_Medical_Form_NCCC

SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSIONS

 

A. Justification

A1.  Need for Information Collection

Through its programs – AmeriCorps State and National, AmeriCorps NCCC, AmeriCorps VISTA, Social Innovation Fund and Senior Corps – the Corporation for National and Community Service (CNCS) engages individuals in national service through by providing resources to states, institutions of higher education, non-profit organizations, Indian tribes, and U.S. Territories. This information collection comprises a set of medical and mental health questions asked of AmeriCorps NCCC applicants to evaluate applicants' physical and mental capacities as are required to perform the essential functions of the AmeriCorps NCCC Member position, with or without reasonable accommodation.

A2.  Indicate how, by whom, and for what purpose the information is to be used.

AmeriCorps NCCC applicants must have the physical and mental capacity required to perform the essential functions of the AmeriCorps NCCC Member position, with or without reasonable accommodation, for which he or she is otherwise eligible. The responses requested and required on this form assist NCCC Medical staff in determining this capacity of applicants to serve in the program as part of a clearance process.

 

 A3.  Minimize Burden: Use of Improved Technology to Reduce Burden

CNCS will be eliciting and accepting responses to these questions via pre-addressed, tracked, UPS envelopes included with the mailings in which applicants receive the blank forms.

A4.  Non-Duplication

There are no other sources of information by which CNCS can meet the purposes described in A2 (above).

 

A5.  Minimizing for economic burden for small businesses or other small entities.

There is no economic burden to any small business or small entities as a result of this collection.

A6.  Consequences of the collection if not conducted, conducted less frequently, as well as any technical or legal obstacles to reducing burden.

 

CNCS and its AmeriCorps NCCC program will not have information necessary to evaluate applicants' physical and mental capacities as are required to perform the essential functions of the AmeriCorps NCCC Member position, with or without reasonable accommodation.

A7.  Special circumstances that would cause information collection to be collected in a manner requiring respondents to report more often than quarterly; report in fewer than 30 days after receipt of the request; submit more than an original and two copies; retain records for more than three years; and other ways specified in the Instructions focused on statistical methods, confidentially, and proprietary trade secrets.

There are no special circumstances that would require the collection of information in these ways.

A8.  Provide copy and identify the date and page number of publication in the Federal Register of the Agency’s notice. Summarize comments received and actions taken in response to comments. Specifically address comments received on cost and hour burden.

The 60 day Notice soliciting comments was published on Wednesday, May 18, 2016, on pages 31227-31228. No comments were received.

 

 A9.  Payment to Respondents

There are no payments or gifts to respondents

  

A10.  Assurance of Confidentiality and its basis in statute, regulation, or agency policy.

Information is confidential, for official use only, and will only be released to personnel on a need-to-know basis.

A11.  Sensitive Questions

 

The information collection does include questions of a sensitive nature. These include questions on current and past medical conditions, immunizations, current and past medications, well-being and mental health, and needed accommodations. As stated on the form that is completed by the individual on whom the information is requested, the information is needed in order to determine whether the medical/mental history and identifiable health risks of individuals will allow them to perform the essential functions of AmeriCorps NCCC participants with or without reasonable accommodation.

 

A12. Hour burden of the collection

These are the medical and mental health questions for AmeriCorps NCCC applicants.

NCCC expects to distribute 8,500 forms each year. Each response is estimated to have a burden of 15 minutes, resulting in 2,125 total estimated burden hours annually.

 

A13. Cost burden to the respondent

There is no cost to the respondent.

 

A14. Cost to Government

There are no additional costs to the Government.

A15. Reasons for program changes or adjustments in burden or cost.

Not applicable.

 

 A16.  Publication of results

Not applicable.

 

A17.  Explain the reason for seeking approval to not display the expiration date for OMB approval of the information collection.

Not applicable.

 

 A18.  Exceptions to the certification statement

There are no exceptions to the certification statement in the submitted ROCIS form.

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