Report of Dental Examinitaion

ICR 201610-0420-004

OMB: 0420-0546

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2016-10-05
IC Document Collections
IC ID
Document
Title
Status
198187 Modified
ICR Details
0420-0546 201610-0420-004
Historical Active 201410-0420-002
PEACE
Report of Dental Examinitaion
Revision of a currently approved collection   Yes
Regular
Approved without change 03/02/2017
Retrieve Notice of Action (NOA) 01/31/2017
  Inventory as of this Action Requested Previously Approved
03/31/2020 36 Months From Approved 02/28/2018
5,600 0 5,400
12,600 0 4,050
1,008,000 0 864,000

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.

US Code: 22 USC 2504(e) Name of Law: Peace Corps Act
  
None

Not associated with rulemaking

  81 FR 63505 09/15/2016
82 FR 8630 01/27/2017
No

1
IC Title Form No. Form Name
Report of Dental Evaluation PC-OMS-1790 Dental S Report of Dental Evaluation

  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
Yes
Changing Regulations
No
The burden increased due to Agency discretion.

$40,380
No
No
No
Yes
No
Uncollected
Denora Miller 202 692-1236 [email protected]

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

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/31/2017


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