Peace Corps Health History Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0420-0510 Health History Form	Form and Instruction	New	Available
Form PC-1789 Health History Form (PC 1789)	Form and Instruction	Unchanged	Available
HHF Supporting Statement 2016(1).docx	Supporting Statement B	Uploaded 2016-11-02	Available
PC-17.pdf	Supplementary Document	Uploaded 2012-07-12	Available
HHF 2016.pdf	Supporting Statement A	Uploaded 2016-11-02	Available
22 USC 2504.pdf	Supplementary Document	Uploaded 2011-06-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
223819	Health History Form	Form and Instruction	New
200891	Health History Form (PC 1789)	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0420-0510	ICR Reference No: 201610-0420-005
Status: Historical Inactive	Previous ICR Reference No: 201401-0420-004
Agency/Subagency: PEACE	Agency Tracking No:
Title: Peace Corps Health History Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 12/09/2016
	Date Received in OIRA: 11/02/2016
Terms of Clearance: Multiple versions of the instrument are uploaded. Please amend the IC list to only indicate the instrument planned for electronic and paper filing .

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2017	36 Months From Approved	03/31/2017
Responses	10,000	0	10,000
Time Burden (Hours)	7,500	0	7,500
Cost Burden (Dollars)	0	0	0

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Abstract: All Peace Corps Volunteer applicants must undergo a physical examination prior to service during the application process to ensure good health and be able to serve without undue disruption due to health problems.

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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 39291	06/16/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 63504	09/15/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Health History Form	0420-0510	Health History Form
Health History Form (PC 1789)	PC-1789, PC-1789	Health History Form ,   Health History Form (paper version)

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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: The burden on this ICR is increased because of program change due to agency discretion.

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Annual Cost to Federal Government: $301,250

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]? 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

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Common Form ICR:  Yes

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

table that charts list of RCF

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: 11/02/2016

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