Report of Dental Examinitaion

Forms and Documents

Document Name	Status
Form PC-OMS-1790 Dental Report of Dental Evaluation Form and Instruction	Modified
Dental-SupportingStatement 2016.docx Supporting Statement A	2016-10-05

IC Document Collections

IC ID	Document Title	Status
198187	Report of Dental Evaluation Form and Instruction	Modified

ICR Details

OMB Control No: 0420-0546	ICR Reference No: 201610-0420-004
Status: Historical Active	Previous ICR Reference No: 201410-0420-002
Agency/Subagency: PEACE	Agency Tracking No:
Title: Report of Dental Examinitaion
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/02/2017
	Date Received in OIRA: 01/31/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	02/28/2018
Responses	5,600	0	5,400
Time Burden (Hours)	12,600	0	4,050
Cost Burden (Dollars)	1,008,000	0	864,000

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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:
	81 FR 63505	09/15/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 8630	01/27/2017
Did the Agency receive public comments on this ICR? No

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

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

	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	5,600	5,400	0	200	0	0
Annual Time Burden (Hours)	12,600	4,050	0	8,550	0	0
Annual Cost Burden (Dollars)	1,008,000	864,000	0	144,000	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden increased due to Agency discretion.

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Annual Cost to Federal Government: $40,380

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:  The Peace Corps is upgrading the medical component of the electronic application process as part of a larger quality improvement project. In conjunction with this project, medical staff have reviewed and revised the medical screening forms including the Health History Form, The Report of Physical Examination, Report of Dental Examination, and the Individual Specific Medical Evaluation Forms. These changes are being made in an effort to: • Reduce the time required for an Applicant and their health care providers to manage and complete the medical forms • Reduce the number of medical forms • Clarify content based on the lessons learned from customer feedback 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 into the Applicant’s secure Peace Corps online portal, faxed, or mailed to the Peace Corps Office of Medical Services.

Approved RCFs using this ICR

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: 01/31/2017

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