Individual Specific Medical Evaluation Forms (15)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form PC-262-14 Mental Health Current Evaluation and Treatment Summary Form	Form and Instruction	New	Available
Form PC-262-16 Required Peace Corps Immunization Documentation Form	Form and Instruction	New	Available
Form PC-262-6 Substance-Related and Addictive Disorders Current Evaluation Form	Form and Instruction	New	Available
Form PC-262-15 Functional Abilities Evaluation Form	Form and Instruction	New	Available
Form PC-262-13 Transfer of Care form	Form and Instruction	New	Available
Form PC-OMS-116 Prescription for Eyeglassess	Form and Instruction	Modified	Repair queued
Form PC-262-10 Insulin Dependent Diabetic Supplemental Documentation Form	Form and Instruction	Modified	Available
Form PC-262-12 Reactive Tuberculin Test Evaluation Form	Form and Instruction	Modified	Available
Form PC-262-7 ECG/EKG Form	Form and Instruction	Modified	Available
Form PC-262-9 Colon Cancer Screening Form	Form and Instruction	Modified	Available
Form PC-262-11 Cervical Cancer Screening Form	Form and Instruction	Modified	Available
Form PC-355-2 Mammogram Waiver Form	Form and Instruction	Modified	Available
Form PC-262-6 Alcohol/Substance Abuse Current Evaluation Form	Form and Instruction	Removed	Available
Form TG-510-2 Mental Health Current Evaluation Form	Form and Instruction	Removed	Available
Form PC-262-8 Eating Disorder Treatment Summary Form	Form and Instruction	Modified	Repair queued
Form TG-510-3 Mental Health Treatment Summary	Form and Instruction	Removed	Available
Form PC-262-4 Low Body Mass Index Evaluation Form	Form and Instruction	Removed	Available
Form PC-262-5 Disease Diagnosis Evaluation Form	Form and Instruction	Removed	Available
Form PC-262-3 Diabetes Evaluation Form	Form and Instruction	Modified	Repair queued
Form PC-262-2 Asthma Evaluation Form	Form and Instruction	Modified	Available
Form PC-262-1 Allergy Treatment Form	Form and Instruction	Removed	Available
0420-0550 Supporting Statement.docx	Supporting Statement A	Uploaded 2017-02-07	Repair queued
PC-17.pdf	Supplementary Document	Uploaded 2012-07-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
224328	Mental Health Current Evaluation and Treatment Summary Form	Form and Instruction	New	Mental Health Current Evaluation and Treatment Summary Form
224327	Required Peace Corps Immunization Documentation Form	Form and Instruction	New	Required Peace Corps Immunization Documentation Form
224326	Substance-Related and Addictive Disorders Current Evaluation Form	Form and Instruction	New	Substance-Related and Addictive Disorders Current Evaluation Form
224325	Functional Abilities Evaluation Form	Form and Instruction	New	Functional Abilities Evaluation Form
224319	Transfer of Care – Request for Information Form	Form and Instruction	New	Transfer of Care form
201724	Prescription for Eyeglassess	Form and Instruction	Modified	Prescription for Eyeglassess
201719	Insulin Dependent Diabetic Supplement Documentation Form	Form and Instruction	Modified	Insulin Dependent Diabetic Supplemental Documentation Form
201718	Reactive Tuberculin Test Evaluation Form	Form and Instruction	Modified	Reactive Tuberculin Test Evaluation Form
201717	ECG/EKG Form	Form and Instruction	Modified	ECG/EKG Form
201716	Colon Cancer Screening Form	Form and Instruction	Modified	Colon Cancer Screening Form
201715	Cervical Cancer Screening Form	Form and Instruction	Modified	Cervical Cancer Screening Form
201714	Mammogram Form	Form and Instruction	Modified	Mammogram Waiver Form
201710	Alcohol/Substance Abuse Current Evaluation	Form and Instruction	Removed	Alcohol/Substance Abuse Current Evaluation Form
201709	Mental Health Current Evaluation	Form and Instruction	Removed	Mental Health Current Evaluation Form
201708	Eating Disorder Treatment Summary Form	Form and Instruction	Modified	Eating Disorder Treatment Summary Form
201707	Mental Health Treatment Summary Form	Form and Instruction	Removed	Mental Health Treatment Summary
201686	Low Body Mass Index Evaluation Form	Form and Instruction	Removed	Low Body Mass Index Evaluation Form
201685	Disease Diagnosis Form	Form and Instruction	Removed	Disease Diagnosis Evaluation Form
201684	Diabetes Diagnosis Form	Form and Instruction	Modified	Diabetes Evaluation Form
201683	Asthma Evaluation Form	Form and Instruction	Modified	Asthma Evaluation Form
201682	Allergy Treatment Form	Form and Instruction	Removed	Allergy Treatment Form

ICR Details

OMB Control No: 0420-0550	ICR Reference No: 201611-0420-001
Status: Historical Active	Previous ICR Reference No: 201401-0420-006
Agency/Subagency: PEACE	Agency Tracking No:
Title: Individual Specific Medical Evaluation Forms (15)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/06/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/07/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	03/31/2017
Responses	18,498	0	16,528
Time Burden (Hours)	19,037	0	31,951
Cost Burden (Dollars)	0	0	0

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Abstract: The 16 forms listed may be sent to an individual Applicant at one of the following times in the medical review process: (1) after the Applicant completes the Health History Form and receives a nomination; (2) after a Peace Corps nurse reviews the Applicant's Health History Form and any completed forms previously requested; or (3) at the time of the Applicant's physical examination. The results of the physical examination and the information contained in the specific evaluation forms will be used to make an individualized determination as to whether an Applicant for Volunteer service will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems.

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Authorizing Statute(s): US Code: 22 USC 2504 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 81179	11/17/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 9402	02/06/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Alcohol/Substance Abuse Current Evaluation	PC-262-6	Alcohol/Substance Abuse Current Evaluation Form
Allergy Treatment Form	PC-262-1	Allergy Treatment Form
Asthma Evaluation Form	PC-262-2	Asthma Evaluation Form
Cervical Cancer Screening Form	PC-262-11	Cervical Cancer Screening Form
Colon Cancer Screening Form	PC-262-9	Colon Cancer Screening Form
Diabetes Diagnosis Form	PC-262-3	Diabetes Evaluation Form
Disease Diagnosis Form	PC-262-5	Disease Diagnosis Evaluation Form
ECG/EKG Form	PC-262-7	ECG/EKG Form
Eating Disorder Treatment Summary Form	PC-262-8	Eating Disorder Treatment Summary Form
Functional Abilities Evaluation Form	PC-262-15	Functional Abilities Evaluation Form
Insulin Dependent Diabetic Supplement Documentation Form	PC-262-10	Insulin Dependent Diabetic Supplemental Documentation Form
Low Body Mass Index Evaluation Form	PC-262-4	Low Body Mass Index Evaluation Form
Mammogram Form	PC-355-2	Mammogram Waiver Form
Mental Health Current Evaluation	TG-510-2	Mental Health Current Evaluation Form
Mental Health Current Evaluation and Treatment Summary Form	PC-262-14	Mental Health Current Evaluation and Treatment Summary Form
Mental Health Treatment Summary Form	TG-510-3	Mental Health Treatment Summary
Prescription for Eyeglassess	PC-OMS-116	Prescription for Eyeglassess
Reactive Tuberculin Test Evaluation Form	PC-262-12	Reactive Tuberculin Test Evaluation Form
Required Peace Corps Immunization Documentation Form	PC-262-16	Required Peace Corps Immunization Documentation Form
Substance-Related and Addictive Disorders Current Evaluation Form	PC-262-6	Substance-Related and Addictive Disorders Current Evaluation Form
Transfer of Care – Request for Information Form	PC-262-13	Transfer of Care form

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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	18,498	16,528	0	1,970	0	0
Annual Time Burden (Hours)	19,037	31,951	0	-12,914	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden changed due to program changes at the agency discretion.

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Annual Cost to Federal Government: $440,661

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:  No

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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: 02/07/2017

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