0420-0550 Supporting Statement

Peace Corps -- Office of Medical Services

Individual Specific Medical Evaluation Forms (15):

Asthma Evaluation Form (PC-262-2) - OMB Control No. 0420-0550

Diabetes Evaluation Form (PC-262-3) - OMB Control No. 0420-0550

Transfer of Care – Request for Information Form (PC-XXX-X) – OMB Control No. 0420-0550

Eating Disorder Treatment Summary Form (PC-262-8) - OMB Control No. 0420-0550

Mental Health Current Evaluation and Treatment Summary Form (PC-XXX-X) - OMB Control No. 0420-0550

Substance-Related and Addictive Disorders Current Evaluation Form (PC-262-6) - OMB Control No. 0420-0550

Insulin Dependent Diabetic Supplemental Documentation Form (PC-262-10) - OMB Control No. 0420-0550

Mammogram Waiver Form (PC-355-2) - OMB Control No. 0420-0550

Cervical Cancer Screening Form (PC-262-11) – OMB Control No. 0420-0550

Colon Cancer Screening Form (PC-262-9) - OMB Control No. 0420-0550

ECG/EKG Form (PC-262-7) - OMB Control No. 0420-0550

Reactive Tuberculin Test Evaluation Form (PC-262-12) - OMB Control No. 0420-0550

Prescription for Eyeglasses Form (PC-OMS-116) - OMB Control No. 0420-0550

Functional Abilities Evaluation Form (PC-XXX-X) - OMB Control No. 0420-0550

Required Peace Corps Immunization Documentation Form (PC-XXX-X) - OMB Control No. 0420-0550

SUPPORTING STATEMENT

Section A. Justification

1. The Peace Corps Act states that “[t]he President may enroll in the Peace Corps for service abroad qualified citizens and nationals of the United States (referred to in this Act as “volunteers”). The terms and conditions of the enrollment … of volunteers shall be exclusively those set forth in this Act and those consistent therewith which the President may prescribe …” 22 U.S.C. 2504(a). Eligibility requirements for the Peace Corps have been prescribed in 22 C.F.R. Part 305. Among those eligibility requirements is one relating to medical status. An Applicant “must, with reasonable accommodation, have the physical and mental capacity required of a Volunteer to perform the essential functions of the Peace Corps Volunteer assignment for which he or she is otherwise eligible and be able to complete an agreed upon tour of service, ordinarily two years, without unreasonable disruption due to health problems.” 22 C.F.R. 305.2(c). All Applicants for service must undergo a physical examination and a dental evaluation prior to Volunteer service to determine if they meet this medical status eligibility requirement. In addition, under 22 U.S.C. 2504(e), the Peace Corps provides medical care to Volunteers during their service and the information collected will be used in connection with medical care and treatment during Peace Corps service for Applicants who become Volunteers. Finally, the information collected may serve as a point of reference for any potential future Volunteer worker’s compensation claims.¹

Volunteers serve in 63 developing countries where western-style healthcare is often not available. Volunteers are placed in remote locations where they may suffer hardship because they have no access to running water and/or electricity. They also may be placed in locations with extreme environmental conditions related to cold, heat or high altitude and they may be exposed to diseases not generally found in the U.S. Volunteers may be placed many hours from the Peace Corps medical office and not have easy access to a health care provider. Therefore, a thorough review of an Applicant’s past medical history is an essential first step to determine their suitability for service in Peace Corps.

All Applicants will begin the medical part of the application process by completing a comprehensive Health History Form, covered under OMB control number 0420-0510. After completion of the Health History Form and after passing preliminary non-health-related assessments, the Applicant will be “invited” to a country specific program that has been preliminarily identified as having the medical resources to meet their health care needs, if any. After an Applicant submits a complete physical examination, as documented in a Report of Physical Examination (covered under OMB control number 0420-0549), and any required supplemental medical evaluations covered by this supporting statement, the Peace Corps preservice medical staff performs a comprehensive medical review which will result in a final determination regarding their medical clearance for Peace Corps service.

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 has 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 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.

The Allergy Treatment (PC-262-1) and Low Body Mass Index Evaluation (PC-262-4) Forms have been retired. The Disease Diagnosis Form (PC-262-5) has been retired and a Transfer of Care – Request for Information Form and Functional Abilities Evaluation Form has been created to address the specific medical information required to make medical clearance determinations. The Mental Health Treatment Summary (TG-510-3) and the Mental Health Current Evaluation Form (TG-510-2) have been combined and renamed Mental Health Current Evaluation and Treatment Summary Form.

The forms covered by this Supporting Statement 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 invitation; (2) after a Peace Corps nurse reviews the Applicant’s Health History Form and any completed forms previously requested; or (3) after the review of an Applicant’s physical examination. The results of the physical examination and the information contained in the specific evaluation forms covered by this Supporting Statement 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 assignment and complete a tour of service without unreasonable disruption due to health problems.

If, based on the Applicant’s responses on the Health History Form, additional information is required in order to make an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems, then one or more of the forms listed below may be sent to the Applicant.

The Asthma Evaluation Form: When an Applicant reports on the Health History Form any history of asthma, he or she will be provided an Asthma Evaluation Form for the treating physician to completeThe Asthma Evaluation Form asks for the physician to document the Applicant’s condition of asthma, including any asthma symptoms, triggers, treatments, or limitations or restrictions due to the condition. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation that may be needed, such as placement of the Applicant within reasonable proximity to a hospital in case treatment is needed for a severe asthma attack.

The Diabetes Diagnosis Form: When an Applicant reports the condition of diabetes Type 1 on the Health History Form, the Applicant will be provided a Diabetes Diagnosis Form for the treating physician to complete. In certain cases, the Applicant may also be asked to have the treating physician complete a Diabetes Diagnosis Form if the Applicant reports the condition of diabetes Type 2 on the Health History Form. The Diabetes Diagnosis Form asks the physician to document the diabetes diagnosis, etiology, possible complications, and treatment. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation that may be needed, such as placement of an Applicant who requires the use of insulin in order to ensure that adequate insulin storage facilities are available at the Applicant’s site.

The Transfer of Care – Request for Information Form: When an Applicant reports on the Health History Form a medical condition of significant severity (other than one covered by another form), he or she may be provided the Transfer of Care – Request for Information Form for the treating physician to complete. The Transfer of Care – Request for Information Form may also be provided to an Applicant whose responses on the Health History Form indicate that the Applicant may have an unstable medical condition that requires ongoing treatment. The Transfer of Care – Request for Information Form asks the physician to document the diagnosis, current treatment, physical limitations and the likelihood of significant progression of the condition over the next three years. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation (e.g., avoidance of high altitudes or proximity to a hospital)that may be needed to manage the Applicant’s medical condition.

The Functional Abilities Evaluation Form: When an Applicant reports on the Health History Form a functional ability limitation he or she will be provided this form to determine the type of accommodation and/or placement program support (e.g., proximity to program site, support support devices) that may be needed to manage the Applicant’s medical condition.. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems.

The Mental Health Current Evaluation and Treatment Summary Form will be used when an Applicant reports on the Health History Form a history of certain serious mental health conditions, such as bipolar disorder, schizophrenia, mental health hospitalization, attempted suicide or cutting, or treatments or medications related to these conditions. In these cases, an Applicant will be provided a Mental Health Current Evaluation and Treatment Summary Form for a licensed mental health counselor, psychiatrist or psychologist to complete. The Mental Health Current Evaluation and Treatment Summary Form asks the counselor, psychiatrist or psychologist to document the dates and frequency of therapy sessions, clinical diagnoses, symptoms, course of treatment, psychotropic medications, mental health history, level of functioning, prognosis, risk of exacerbation or recurrence while overseas, recommendations for follow up and any concerns that would prevent the Applicant from completing 27 months of service without unreasonable disruption. A current mental health evaluation might be needed if information on the condition is out-dated or previous reports on the condition do not provide enough information to adequately assess the current status of the condition.This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation that may be needed, such as placement of the Applicant in a country with appropriate mental health support.

The Eating Disorder Treatment Summary Form will be used when an Applicant reports a past or current eating disorder diagnosis in the Health History Form. In these cases the Applicant is provided an Eating Disorder Treatment Summary Form for a mental health specialist, preferably with eating disorder training, to complete. The Eating Disorder Treatment Summary Form asks the mental health specialist to document the dates and frequency of therapy sessions, clinical diagnoses, presenting problems and precipitating factors, symptoms, Applicant’s weight over the past three years, relevant family history, course of treatment, psychotropic medications, mental health history inclusive of eating disorder behaviors, level of functioning, prognosis, risk of recurrence in a stressful overseas environment, recommendations for follow up, and any concerns that would prevent the Applicant from completing 27 months of service without unreasonable disruption due to the diagnosis. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation that may be needed, such as placement of the Applicant in a country with appropriate mental health support.

The Substance-Related and Addictive Disorders Current Evaluation Form is used when an Applicant reports in the Health History Form a history of substance abuse (i.e., alcohol or drug related problems such as blackouts, daily or heavy drinking patterns or the misuse of illegal or prescription drugs) and that this substance abuse affects the Applicant’s daily living or that the Applicant has ongoing symptoms of substance abuse. In these cases, the Applicant is provided an Substance-Related and Addictive Disorders Current Evaluation Form for a substance abuse specialist to complete. The Substance-Related and Addictive Disorders Current Evaluation Form asks the substance abuse specialist to document the history of alcohol/substance abuse, dates and frequency of any therapy sessions, which alcohol/substance abuse assessment tools were administered, mental health diagnoses, psychotropic medications, self harm behavior, current clinical assessment of alcohol/substance use, clinical observations, risk of recurrence in a stressful overseas environment, recommendations for follow up, and any concerns that would prevent the Applicant from completing a tour of service without unreasonable disruption due to the diagnosis. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation that may be needed, such as placement of the Applicant in a country with appropriate sobriety support or counseling support.

The Mammogram Waiver Form is used for all Applicants who have female breasts and will be 50 years of age or older during service who wish to waive routine mammogram screening during service. If an Applicant waives routine mammogram screening during service, the Applicant’s physician is asked to complete this form in order to make a general assessment of the Applicant’s statistical breast cancer risk and discussed the results with the Applicant including the potential adverse health consequence of foregoing screening mammography.

The Cervical Cancer Screening Form is used with all Applicants with a cervix. Prior to medical clearance, female Applicants are required to submit a current cervical cancer screening examination and Pap cytology report based the American Society for Colploscopy and Cervical Pathology (ASCCP) screening time-line for their age and Pap history. This form assists the Peace Corps in determining whether an Applicant with mildly abnormal Pap history will need to be placed in a country with appropriate support.

The Colon Cancer Screening Form is used with all Applicants who are 50 years of age or older to provide the Peace Corps with the results of the Applicant’s latest colon cancer screening. Any testing deemed appropriate by the American Cancer Society is accepted. The Peace Corps uses the information in the Colon Cancer Screening Form to determine if the Applicant currently has colon cancer. Additional instructions are included pertaining to abnormal test results.

The ECG/EKG Form is used with all Applicants who are 50 years of age or older to provide the Peace Corps with the results of an electrocardiogram. The Peace Corps uses the information in the electrocardiogram to assess whether the Applicant has any cardiac abnormalities that might affect the Applicant’s service. Additional instructions are included pertaining to abnormal test results. The electrocardiogram is performed as part of the Applicant’s physical examination.

The Reactive Tuberculin Test Evaluation Form is used when an Applicant reports a history of treatment for active tuberculosis or a history of a positive tuberculosis (TB) test on their Health History Form or if a positive TB test result is noted as a component of the Applicant’s physical examination findings. In these cases, the Applicant is provided a Reactive Tuberculin Test Evaluation Form for the treating physician to complete. The treating physician is asked to document the type and date of a current TB test, TB test history, diagnostic tests if indicated, treatment history, risk assessment for developing active TB, current TB symptoms, and recommendations for further evaluation and treatment. In the case of a positive result on the TB test, a chest x-ray may be required, along with treatment for latent TB.

The Insulin Dependent Supplemental Documentation Form is used with Applicants who have reported on the Health History Form that they have insulin dependent diabetes. In these cases, the Applicant is provided an Insulin Dependent Supplemental Documentation Form for the treating physician to complete. The Insulin Dependent Supplemental Documentation Form asks the treating physician to document that he or she has discussed with the Applicant medication (insulin) management, including whether an insulin pump is required, as well as the care and maintenance of all required diabetes related monitors and equipment. This form assists the Peace Corps in determining whether the Applicant will be in need of insulin storage while in service and, if so, will assist the Peace Corps in determining an appropriate placement for the Applicant.

The Prescription for Eyeglasses Form is used with Applicants who have reported on the Health History Form that they use corrective lenses or otherwise have uncorrected vision that is worse than 20/40. In these cases, Applicants are provided a Prescription for Eyeglasses Form for their prescriber to indicate eyeglasses frame measurements, lens instructions, type of lens, gross vision and any special instructions. This form is used in order to enable the Peace Corps to obtain replacement eyeglasses for a Volunteer during service.

The Required Peace Corps Immunizations Form is used to informed Applicants of the specific vaccines and/or documented proof of immunity required for medical clearance for the specific country of service. The form advises the Applicant that all other Center for Disease Control (CDC) recommended vaccinations will be administered after arrival in-country. This form assists the Peace Corps with establishing a baseline of the Applicants immunization history and prepare for any additional vaccines recommended for country of service.

2. The information in these forms will be used by the Peace Corps Office of Medical Services to determine whether an Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems. If it is determined that the Applicant has a reasonable chance of performing the essential assignment functions and completing a tour of service, the forms will also be used to establish the level of medical and other support, if any, that may be required to reasonably accommodate the Applicant. The information in these forms are used as a baseline assessment for the Peace Corps Medical Officers overseas who are responsible for the Volunteer’s medical care. Finally, the Peace Corps may use the information in the forms as a point of reference in the event that, after completion of the Applicant’s service as a Volunteer, he or she makes a worker’s compensation claim under the Federal Employee Compensation Act (FECA).

Applicants’ qualifications for service are reviewed in a division of Peace Corps separate from the division that performs the medical clearance review. Those who make a judgment about whether an Applicant has the skills to serve as a Volunteer do not have access to medical clearance information about the Applicant. Additionally, each Applicant receives an individualized assessment of his or her medical conditions. Peace Corps does not have a blanket rule excluding Applicants with particular conditions. Applicants who are medically disqualified receive an explanation why they were not medically cleared, and they have the opportunity to appeal the clearance decision to the Pre-Service Review Board. Medical clearance decisions are not permanent, and Applicants who are not medically cleared may reapply.

3. 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 has reviewed and revised the medical screening forms including the Health History Form, Report of Physical Examination, Report of Dental Examination, and the Individual Specific Medical Evaluation Forms. These changes are an effort to reduce time required for an Applicant and their health care providers to manage and complete the medical forms, reducing the number of medical forms and clarifying content based on the lessons learned from customer and health care provider feedback. Applicants will gain access to the forms via a secure online portal. Applicants will have to download the forms for their health care providers to complete. Completed forms can be scanned and uploaded back into the Applicant’s secure Peace Corps online portal or they can be faxed or mailed to the Peace Corps Office of Medical Services. The Peace Corps anticipates that most Applicants will submit the forms electronically and that only those with no electronic access will submit a paper version. Applicant’s health care provider does not have access to the Applicant’s secure Peace Corps online portal therefore unable to complete and sign the these form’s electronically.

4. There is no similar information available to the Peace Corps. These forms are the only agency forms that collect this particular information concerning an Applicant’s asthma, diabetes, diseases of significant severity, mental health, eating disorder, alcohol or other substance abuse, mammogram, Pap screening, colon cancer screening, eyeglass prescription or tuberculosis. While there are other medical forms, none of them addresses these conditions, treatments or needs with this degree of specificity. It would not make sense to combine these forms with any of the other medical forms, as the Office of Medical Services will send these forms only to those specific Applicants with a history of the particular condition or who are of a particular age and gender.

5. This collection does not impact small business or other small entities.

6. Those Applicants who have self-identified a medical condition of significant severity on the Health History Form or who are of a particular age and gender will receive one or more of the forms described above to better assess whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems and, if so, what accommodation may be needed. If the Peace Corps lacked the medical information obtained during the medical screening process, the Peace Corps would be unable to conduct the assessment.

7. There are no special circumstances. Collection will be conducted consistent with 5 C.F.R. 1320.6 guidelines.

8. The agency’s 60- Day notice was published in the Federal Register on November 11, 2016, 81 FR 81179. No public comments were received during the 60-day period. The 30- Day notice was published on February 6, 2017, 82 FR 9402.

9. No payment or gift is provided to Applicants applying for Peace Corps service. However, under 22 U.S.C. 2504(e), “Applicants for enrollment shall receive such health examinations preparatory to their service … as the President may deem necessary or appropriate.” In accordance with the authority provided in 22 U.S.C. 2504(e), the Peace Corps reimburses Applicants for some of the expenses that they incur for medical examinations that they undergo in connection with the Peace Corps Volunteer application process. This reimbursement is subject to overall limits and may not cover all costs incurred by the Applicant in connection with the medical evaluation. As there are different requirements for medical evaluations based on gender and age, the reimbursement limits vary based on those factors:

Females under 50 may be reimbursed up to $165

Females 50 and older may be reimbursed up to $290

Males under 50 may be reimbursed up to $125

Males 50 and older may be reimbursed up to $175

In addition, Applicants are reimbursed only to the extent that they are not otherwise reimbursed by their insurance companies. Peace Corps is seeking Paperwork Reduction Act approval for these forms.

10. Applicants are informed that the medical information they provide will be maintained in accordance with the Privacy Act. Applicant medical records are included in a sub-system of the Peace Corps’ Privacy Act System of Records: Volunteer Applicant and Service Records System (PC-17). The collection and storage of this information also complies with the Health Insurance Portability and Accountability Act (HIPAA). The Peace Corps’ internal rules ensure the confidential protection of medical information consistent with the Privacy Act and HIPAA. Applicants are informed of their rights under HIPAA before completing the forms.

11. Questions of a sensitive nature are asked solely from a medical perspective and the information gathered is used to determine whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without unreasonable disruption due to health problems. This information also assists the Peace Corps in determining what is needed in order to provide adequate medical support to the Applicant during service. Peace Corps Volunteers serve in countries that have a different healthcare infrastructure than that found in the United States. Therefore, it is essential to fully understand each Applicant’s complete medical history, treatments and response to treatment, as well as a baseline evaluation of all conditions. The Peace Corps complies with the medical confidentiality requirements of the Privacy Act and HIPAA. However, all Applicants are required, as a condition of processing their applications and of Peace Corps service, to sign an Authorization for Peace Corps Use of Medical Information under which the Applicant permits the Peace Corps to use the Applicant’s protected health information to determine the Applicant’s eligibility for the Peace Corps and as necessary for administration of the Peace Corps program.

12. Estimates of hour burden:

Asthma Evaluation Form

During the past year, the Office of Medical Services sent 658 Asthma forms to Applicants who reported a history of asthma. It is estimated that 700 Applicants who have been invited for service will receive the Asthma Evaluation Form each year.

It is anticipated that the Applicant will arrange for the form to be completed by the Applicant’s physician by bringing the form to the physician’s office for completion and waiting for the physician to complete the form (and, if necessary, being examined by the physician). It is estimated that the time associated with the Applicant downloading the form, driving to and from the physician’s office and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the physician office of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. It is estimated that it will take both the Applicant and the physician 30 minutes for the office visit, during which the Applicant will be examined by the physician (if necessary) and the physician will complete the form. The estimate of the total annual hour burden to each Applicant completing the information on this form, inclusive of the time to go to and from the physician, being examined by the physician (if necessary) and waiting for the physician to complete the form and the associated paperwork retrieval and return, is therefore 1 hour 15 minutes. The estimate of the total annual hour burden to each Applicant’s physician completing the information on this form is 30 minutes.

The estimate of total annual hour burden to all physicians and Applicants completing the information on this form is 350 hours of physician time (700 Applicants x 30 minutes) and 875 hours of Applicant time (700 Applicants x 75 minutes).

Diabetes Evaluation Form

During the past year, the Office of Medical Services sent 55 diabetes forms to Applicants who reported diabetes Type 1 or Type 2. It is estimated that, the same number of Applicants who have been invited for service will be required to complete the Diabetes Evaluation Form each year.

Many of the Applicants who report diabetes in their health histories will need to see a physician to complete the Diabetes Diagnosis Form. It is anticipated that the Applicant will arrange for the form to be completed by the Applicant’s physician by bringing the form to the physician’s office for completion and waiting for the physician to complete the form (and, if necessary, being examined by the physician). It is estimated that the time associated with the Applicant downloading the form, driving to and from the physician’s office and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the physician office of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. It is estimated that it will take both the Applicant and the physician 30 minutes for the office visit, during which the Applicant will be examined by the physician (if necessary) and the physician will complete the form. The estimate of the total annual hour burden to each Applicant completing the information on this form, inclusive of the time to go to and from the physician, being examined by the physician (if necessary) and waiting for the physician to complete the form and the associated paperwork retrieval and return, is therefore 1 hour 15 minutes. The estimate of the total annual hour burden to each Applicant’s physician completing the information on this form is 30 minutes.

The estimate of total annual hour burden to all physicians and Applicants completing the information on this form is 28 hours of physician time (55 Applicants x 30 minutes) and 69 hours of Applicant time (55 Applicants x 75 minutes).

Transfer of Care – Request for Information Form

Based on the number of Applicants in previous years who reported a medical condition of significant severity (other than one covered by another form), it is estimated that 1270 Applicants who have been invited for service will receive this form each year.

It is anticipated that the Applicant will arrange for the form to be completed by the Applicant’s physician by bringing the form to the physician’s office for completion and waiting for the physician to complete the form (and, if necessary, being examined by the physician). It is estimated that the time associated with the Applicant downloading the form, driving to and from the physician’s office and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the physician office of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. It is estimated that it will take both the Applicant and the physician 30 minutes for the office visit, during which the Applicant will be examined by the physician (if necessary) and the physician will complete the form. The estimate of the total annual hour burden to each Applicant completing the information on this form, inclusive of the time to go to and from the physician, being examined by the physician (if necessary) and waiting for the physician to complete the form and the associated paperwork retrieval and return, is therefore 1 hour 15 minutes. The estimate of the total annual hour burden to each Applicant’s physician completing the information on this form is 30 minutes.

The estimate of total annual hour burden to all physicians and Applicants completing the information on this form is 635 hours of physician time (1270 Applicants x 30 minutes) and 1588 hours of Applicant time (1270 Applicants x 75 minutes).

Mental Health Current Evaluation and Treatment Summary Form

Last year, approximately 1221 Applicants reported a history of bipolar disorder, schizophrenia, mental health hospitalization, attempted suicide, cutting or another serious mental health condition, treatment or medication. It is therefore estimated that 1221 Applicants who have been invited for service each year will receive a Mental Health Current Evaluation and Treatment Summary Form.

The Applicant will need to see a mental health professional to complete the Mental Health Treatment Summary Form. It is anticipated that the Applicant will arrange for the form to be completed by the mental health professional by bringing the form to the mental health professional’s office for completion and waiting for the mental health professional to complete the form (and, if necessary, being examined by the mental health professional ). It is estimated that the time associated with the Applicant downloading the form, driving to and from the mental health professional’s office and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the mental health professional’s office of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. It is estimated that it will take both the Applicant and the mental health professional 60 minutes for the office visit, during which the Applicant will be examined by the mental health professional (if necessary) and the mental health professional will complete the form. The estimate of the total annual hour burden to each Applicant completing the information on this form, inclusive of the time to go to and from the mental health professional, being examined by the mental health professional (if necessary) and waiting for the mental health professional to complete the form and the associated paperwork retrieval and return, is therefore 1 hour 45 minutes. The estimate of the total annual hour burden to each mental health professional completing the information on this form is 1 hour.

The estimate of total annual hour burden to all mental health professionals and Applicants completing the information on this form is 1221 hours of mental health professional time (1221 Applicants x 60 minutes) and 2137 hours of Applicant time (1221 Applicants x 105 minutes).

The Functional Abilities Evaluation Form

Last year, approximately 300 invited Applicants reported a decrease in their functional ability. It is therefore estimated that 300 Applicants who have been invited for service each year will receive the Functional Abilities Evaluation Form. It is estimated that the time associated with the Applicant downloading the form, driving to and from the provider is part of the process associated with the performance of the physical examination. It is anticipated that this form will be completed when the Applicant goes to a physician for the required physical examination. The estimate of the total annual hour burden to each Applicant completing the information on this form and the associated paperwork retrieval and return, is therefore included in the burden associated with the physical examination.

Eating Disorder Treatment Summary Form

Last year, 282 Applicants reported a past or current eating disorder diagnosis. Based on this, it is estimated that 282 Applicants who has been invited for service each year will receive an Eating Disorder Treatment Summary Form.

It is anticipated that the Applicant will arrange for the form to be completed by the mental health professional by bringing the form to the mental health professional’s office for completion and either waiting for the mental health professional to complete the form or completing the form jointly with the mental health professional. It is estimated that the time associated with the Applicant downloading the form, driving to and from the mental health professional’s office and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the mental health professional’s office of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. It is estimated that it will take both the Applicant and the mental health professional 60 minutes for the office visit, during which the mental health professional will complete the form either alone or jointly with the Applicant. The estimate of the total annual hour burden to each Applicant completing the information on this form, inclusive of the time to go to and from the mental health professional , being examined by the mental health professional (if necessary) and waiting for the mental health professional to complete the form and the associated paperwork retrieval and return, is therefore 1 hour 45 minutes. The estimate of the total annual hour burden to each mental health professional completing the information on this form is 1 hour.

The estimate of total annual hour burden to all mental health professionals and Applicants completing the information on this form is 282 hours of mental health professional time (282 Applicants x 60 minutes) and 494 hours of Applicant time (282 Applicants x 105 minutes).

Substance-Related and Addictive Disorders Current Evaluation Form

Last year, 373 Applicants reported a history of substance abuse. Since only those Applicants who report that their daily living is affected by substance abuse or who report ongoing symptoms of substance abuse will receive the Alcohol/Substance Abuse Evaluation Form, it is estimated that 373 Applicants who have been nominated for service each year will receive the Alcohol/Substance Abuse Evaluation Form.

The Applicant will need to meet with a substance abuse specialist to complete the Alcohol/Substance Abuse Evaluation Form. It is estimated that the time associated with the Applicant downloading the form, driving to and from the substance abuse specialist’s office and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the mental health professional’s office of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. The office visit should require no more than 60 minutes for the substance abuse specialist to meet with the Applicant and complete the form. It is estimated the Applicant will require another 60 minutes to write the personal statement and gather references required by the form.

The estimate of total annual hour burden to each Applicant of completing the information on this form is 2 hours 45 minutes. The estimate of total annual hour burden to each substance abuse specialist of completing the information on this form is 1 hour.

The estimate of total annual hour burden to substance abuse specialists and Applicants completing the information on this form is 373 hours of addiction specialist time (373 Applicants x 60 minutes) and 1026 hours of Applicant time (373 Applicants x 165 minutes).

Mammogram Waiver Form

Last year, 148 female Applicants 50 years of age or older accepted an invitation and requested a waiver of routine mammogram screening during service. It is estimated that the same number of Applicants will receive the Mammogram Form each year. It is estimated that the time associated with the Applicant downloading the form, driving to and from the facility where the mammogram is performed and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the facility of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. It is estimated that it will take the Applicant 60 minutes for the mammogram.

In addition, if the Applicant waives routine mammogram screening while in service, the Applicant will need to see a physician to complete the form. It is anticipated that this part of the form will be completed when the Applicant goes to a physician for the required physical examination. The estimate of the total annual hour burden to each Applicant completing the information on this form, inclusive of the time to go to and from the facility where the mammogram is performed (if necessary) and the associated paperwork retrieval and return, is therefore 1 hour 45 minutes.

The estimate of total annual hour burden to all Applicants obtaining a mammogram, getting the result and completing the form is 259 hours (148 Applicants x 105 minutes).

Cervical Cancer Screening Form

Last year, 3,600 female Applicants accepted an invitation to serve in the Peace Corps. It is estimated that the approximately 3700 Applicants will receive the Cervical Cancer Screening Form in upcoming years.

It is anticipated that the information for this form will be completed when the Applicant goes to a physician for the required physical examination. Based on phone interviews with nine current Peace Corps applicants undergoing the medical evaluation process, it is estimated that the time associated with the Applicant downloading the form and scanning and uploading, faxing or mailing the completed form will be 10 minutes. Because the screening will take place at the same time as the physical examination, there is no additional driving time required. The Pap screening itself is estimated to take 30 minutes for both the Applicant and the physician.

The estimate of total annual hour burden to all physicians and Applicants completing the information on this form is 1800 hours of physician time (3600 Applicants x 30 minutes) and 2400 hours of Applicant time (3600 Applicants x 40 minutes).

Colon Cancer Screening Form

Last year, 575 Applicants 50 years of age or older accepted an invitation to serve. It is estimated that the same number of Applicants will receive the Colon Cancer Screening Form each year.

If the Applicant has not had recent colon cancer screening in accordance with American Cancer Society recommendations, the Applicant will need to have colon cancer screening in order to complete the form. It is estimated that the time associated with the Applicant downloading the form, driving to and from the facility where the colon cancer screening is performed and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the facility of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. It is estimated that it will take the Applicant between 15 minutes and 2 hours for the colon cancer screening to be completed depending on which type of screening is performed. The estimate of the total annual hour burden to each Applicant completing the information on this form, inclusive of the time to go to and from the facility where the colon cancer screening is performed (if necessary) and the associated paperwork retrieval and return, is therefore between 1 hour and 2 hours 45 minutes.

The estimate of total annual hour burden range to all Applicants obtaining colon cancer screening, getting the result and completing the form is between 575 hours (575 Applicants x 60 minutes) and 1581 hours (575 Applicants x 165 minutes).

ECG Form

Last year, 575 Applicants 50 years of age or older accepted an invitation to serve. It is estimated that the same number of Applicants will receive the ECG Form each year.

It is anticipated that this form will be completed when the Applicant goes to a physician for the required physical examination. It is estimated that the time associated with the Applicant downloading the form and scanning and uploading, faxing or mailing the completed form will be 10 minutes. Because the screening will take place at the same time as the physical examination, there is no additional driving time required. The electrocardiogram itself is estimated to take 15 minutes for both the Applicant and the physician. The estimate of total annual hour burden to each Applicant of completing the information on this form is therefore 25 minutes. The estimate of total annual hour burden to each physician of completing the information on this form is 15 minutes.

The estimate of total annual hour burden to all physicians and Applicants completing the information on this form is 144 hours of physician time (575 Applicants x 15 minutes) and 240 hours of Applicant time (575 Applicants x 25 minutes).

Reactive Tuberculin Test Evaluation Form

Last year, 392 Applicants reported a history of reactivity to tuberculosis skin testing or a history of BCG vaccination or had a reactivity discovered as part of their physical examination. It is estimated that the same number of Applicants will receive the Reactive Tuberculin Test Evaluation Form each year.

All Applicants will need to see a health professional to complete the form. It is estimated that the time associated with the Applicant downloading the form, driving to and from the health professional’s office and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the health professional’s office of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. Office visits should require no more than 30 minutes in order for the treating health professional to review the results with the Applicant and complete the form. In the event of a positive TB test, it is estimated the Applicant would need another 30 minutes for a chest x-ray. The estimate of total annual hour burden to each Applicant returning this completed form, inclusive of the time to go to and from the medical office visit and the associated paperwork retrieval and return is therefore 75 minutes to 105 minutes. The estimate of total annual hour burden to each health professional of completing the information on this form is 30 minutes.

The estimate of total annual hour burden to all health professionals and Applicants completing the information on this form is 196 hours of health professional time (392 Applicants x 30 minutes) and between 490 hours (392 Applicants x 75 minutes) and 686 hours (392 Applicants x 105 minutes) of Applicant time.

Insulin Dependent Supplemental Documentation Form

Last year, 14 Applicants who accepted an invitation to serve reported being insulin dependent. It is estimated that the same number of Applicants will receive the Insulin Dependent Supplemental Documentation Form each year.

It is anticipated that this form will be completed when the Applicant goes to a physician for the required physical examination. It is estimated that the time associated with the Applicant downloading the form and scanning and uploading, faxing or mailing the completed form will be 10 minutes. Because the form will be completed at the same time as the physical examination, there is no additional driving time required. Completion of the form is estimated to take no longer than 60 minutes additional time for both the Applicant and the physician. The estimate of total annual hour burden to each Applicant returning this completed form is therefore 70 minutes. The estimate of total annual hour burden to each physician completing the information on this form is 60 minutes.

The estimate of total annual hour burden to all physicians and Applicants completing the information on this form is 14 hours of physician time (14 Applicants x 60 minutes) and 16 hours of Applicant time (14 Applicants x 70 minutes).

Prescription for Eyeglasses Form

Last year, approximately 3293 Applicants accepted an invitation to serve. It is estimated that approximately 64% of Applicants will have a history of using corrective lenses or will otherwise have uncorrected vision that is worse than 20/40. It is therefore estimated that 3293 Applicants will receive the Prescription for Eyeglasses Form each year.

All Applicants with corrective lenses will need to see a prescriber to complete the form. It is estimated that the time associated with the Applicant downloading the form, driving to and from the prescriber’s office and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the prescriber’s office of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. Office visits should require no more than 15 minutes in order for the prescriber and Applicant to complete the form.

The estimate of total annual hour burden to each Applicant returning this completed form, inclusive of the time to go to and from the medical office visit and the associated paperwork retrieval and return is therefore 60 minutes.

The estimate of total annual hour burden to each prescriber of completing the information on this form is 15 minutes.

Required Peace Corps Immunization Documentation Form

It is estimated that 5,600 Applicants will be required to submit documentation of Peace Corps required vaccinations and/or proof of immunity. It is estimated that the minimum time associated with the Applicant collection, review and uploading of their immunization record to be 60 minutes.

The estimate of total annual hour burden to all Applicants submitting vaccination and/or proof of immunity records is 5600 hours (5600 Applicants x 60 minutes).

13. The estimate of total annual cost burden to Applicant respondents resulting from collection of the information in these forms is the total costs of all medical exams that go beyond the maximum Peace Corps reimbursement, which is discussed in response to question 9. The Peace Corps is unable to estimate this overall cost due to the variety of fees that physicians and other health professionals charge and due to the unknown value of insurance reimbursements.

14. Estimated annual cost to the Federal Government: There is no start-up cost associated with these forms. They are inseparable from the costs that Peace Corps reported in its recent justification for the Health History Form for which Peace Corps submitted a justification to OMB on January 10, 2017. The estimated costs below reflect the additional time needed to review the information in these forms over and above the time needed to review other medical information collected from the Applicant in the Health History Form and the Report of Physical Examination. Due to the fact that conditions may require a mental health professional review as well as nurse review, both of these review times are captured.

For those Applicants who become Volunteers, the information in these forms will also be used by Peace Corps Medical Officers overseas in providing medical care during the Volunteer’s service. The costs associated with the receipt and review of this information is indeterminate based on the wide range of Peace Corps Medical Officer hourly rates and the time associated with review of the medical reports in individual cases. It is understood that this is part of an everyday job requirement for all the Peace Corps Medical Officers in the field and reviewing these forms in no way increases the costs to the Federal Government. If Peace Corps Medical Officer did not have the information in these forms, they would have to acquire the information through some other means, which would add to their daily workload.

The remaining forms are reviewed by a nurse, who then consults with a physician or mental health professional. Pre-service Nurses are on the FS-4 pay scale but each has a different pay step depending on experience. For this reason, we are using the mid-range FS-4 hourly rate of $36 an hour, which is $46 an hour with benefit costs included. Physicians and mental health professionals are paid at the FS-1 pay scale with a mid-range rate of $68 an hour, which is $86 an hour with benefit costs included.

Asthma Evaluation Form

It is estimated that 700 Applicants will be required to complete this form with a physician and return it to the Peace Corps. It is expected that it will take a nurse approximately 45 minutes to review the information, including 15 minutes for consulting with a physician. The estimated cost for nurse review is $24,150 (700 Applicants x 45 minutes x $46/hr) . The estimated cost for the consulting physician is $15,050 (700 Applicants x 15 min x $86/hr). The estimate of total annual burden to the Peace Corps resulting from collection of this information is $39,200.

Diabetes Diagnosis Form

It is estimated that 55 Applicants will be required to complete this form with a physician and return it to the Peace Corps. It is expected that it will take a nurse approximately 45 minutes to review the information, including 15 minutes for consulting with a physician. The estimated cost for nurse review is $1,898 (36 Applicants x 45 minutes x $46/hr) . The estimated cost for the consulting physician is $1183 (55 Applicants x 15 min x $86/hr). The estimate of total annual burden to the Peace Corps resulting from collection of this information is $2,081.

Transfer of Care – Request for Information Form

It is estimated that 1270 Applicants will be required to complete this form with a physician and return it to the Peace Corps. It is expected that it will take a nurse approximately 45 minutes to review the information, including 15 minutes for consulting with a physician. The estimated cost for nurse review is $43,815 (1270 Applicants x 45 minutes x $46/hr) . The estimated cost for the consulting physician is $81,915 (1270 Applicants x 15 min x $86/hr). The estimate of total annual burden to the Peace Corps resulting from collection of this information is $125,730.

Mental Health Current Evaluation and Treatment Summary Form

It is estimated that 1221 Applicants will be required to complete this form with a mental health professional and return it to the Peace Corps. It is expected that it will take a nurse approximately 45 minutes to review the information, including 15 minutes for consulting with a mental health professional. The estimated cost for nurse review is $42,125 (1221 Applicants x 45 minutes x $46/hr) . The estimated cost for the consulting mental health professional is $26,252 (1221 Applicants x 15 min x $86/hr). The estimate of total annual burden to the Peace Corps resulting from collection of this information is $68,377.

The Functional Abilities Evaluation Form

It is estimated that 300 Applicants will be required to complete this form and return it to the Peace Corps. It is expected that it will take a nurse approximately 15 minutes to review the information, in most cases without any need to consult with a physician. The estimated cost for nurse review is $3,450 (300 Applicants x 15 minutes x $46/hr).

Eating Disorder Treatment Summary Form

It is estimated that 282 Applicants will be required to complete this form with a mental health professional and return it to the Peace Corps. It is expected that it will take a nurse approximately 45 minutes to review the information, including 15 minutes for consulting with a mental health professional. The estimated cost for nurse review is $9,729 (282 Applicants x 45 minutes x $46/hr) . The estimated cost for the consulting mental health professional is $6,063 (282 Applicants x 15 min x $86/hr). The estimate of total annual burden to the Peace Corps resulting from collection of this information is $15,792.

Substance-Related and Addictive Disorders Current Evaluation Form

It is estimated that 373 Applicants will be required to complete this form with a substance abuse specialist and return it to the Peace Corps. It is expected that it will take a nurse approximately 45 minutes to review the information, including 15 minutes for consulting with a mental health professional. The estimated cost for nurse review is $12,869 (373 Applicants x 45 minutes x $46/hr) . The estimated cost for the consulting mental health professional is $8,020 (373 Applicants x 15 min x $86/hr). The estimate of total annual burden to the Peace Corps resulting from collection of this information is $20,889.

Mammogram Waiver Form

It is estimated that 211 Applicants will be required to complete this form and return it to the Peace Corps. It is expected that it will take a nurse approximately 15 minutes to review the information, in most cases without any need to consult with a physician. The estimated cost for nurse review is $2,427 (211 Applicants x 15 minutes x $46/hr).

Cervical Cancer Screening Form

It is estimated that 3700 Applicants will be required to complete this form and return it to the Peace Corps. It is expected that it will take a nurse approximately 15 minutes to review the information, in most cases without any need to consult with a physician. The estimated cost for nurse review is $42,550 (3700 Applicants x 15 minutes x $46/hr).

Colon Cancer Screening Form

It is estimated that 575 Applicants will be required to complete this form and return it to the Peace Corps. It is expected that it will take a nurse approximately 15 minutes to review the information, in most cases without any need to consult with a physician. The estimated cost for nurse review is $6,613 (575 Applicants x 15 minutes x $46/hr).

ECG Form

It is estimated that 575 Applicants will be required to complete this form and return it to the Peace Corps. It is expected that it will take a nurse approximately 15 minutes to review the information, in most cases without any need to consult with a physician. The estimated cost for nurse review is $6,613 (575 Applicants x 15 minutes x $46/hr).

Reactive Tuberculin Test Evaluation Form

It is estimated that 392 Applicants will be required to complete this form and return it to the Peace Corps. It is expected that it will take a nurse approximately 15 minutes to review the information. It does not require consultation with a physician. The estimated cost for nurse review is $4,508 (392 Applicants x 15 minutes x $46/hr).

Insulin Dependent Supplemental Documentation Form

It is estimated that 14 Applicants will be required to complete this form and return it to the Peace Corps. It is expected that it will take a nurse approximately 15 minutes to review the information. It does not require consultation with a physician. The estimated cost for nurse review is $161 (14 Applicants x 15 minutes x $46/hr).

Prescription for Eyeglasses Form

It is estimated that 3,293 Applicants will be required to complete this form and return it to the Peace Corps. It is expected that it will take a nurse approximately 15 minutes to review the information. It does not require consultation with a physician. The estimated cost for nurse review is $37,870 (3,293 Applicants x 15 minutes x $46/hr).

The cost figures are adjusted to reflect the range of costs involved with these particular data collections. Costs associated with reviewing the Health History Form and the Report of Physical Examination used in the medical screening process are reflected on the supporting statements for those respective forms.

Required Peace Corps Immunization Documentation Form

It is estimated that 5,600 Applicants will be required to complete this form and return it to the Peace Corps. It is expected that it will take a nurse approximately 15 minutes to review the information. It does not require consultation with a physician. The estimated cost for nurse review is $64,400 (5,600 Applicants x 15 minutes x $46/hr).

15. There are no changes to report.

16. This information will not be quantified or published.

17. The Agency is not seeking approval to conceal or omit the expiration date for OMB approval of the information collection.

18. The agency is able to certify compliance with all provisions under Item 19 of OMB Form 83-I.

Section B. Collection of Information Employing Statistical Methods

This collection of information does not employ statistical methods.

1 The Peace Corps Act states that, except as provided in the Peace Corps Act, Volunteers are not employees for any purpose. 22 U.S.C. § 2504(a). Nevertheless, Volunteers are entitled to receive compensation under the Federal Employees Compensation Act for injuries received during service. 5 U.S.C. § 8142.

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