Peace Corps Health History Form

ICR 201612-0420-002

OMB: 0420-0510

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2017-02-10
Supplementary Document
2017-02-10
Supplementary Document
2012-07-12
Supporting Statement A
2017-02-10
Supplementary Document
2011-06-21
IC Document Collections
IC ID
Document
Title
Status
200891 Modified
ICR Details
0420-0510 201612-0420-002
Historical Active 201401-0420-004
PEACE PC-1789
Peace Corps Health History Form
Revision of a currently approved collection   Yes
Regular
Approved with change 02/10/2017
Retrieve Notice of Action (NOA) 12/20/2016
Peace Corps must submit an amended request to OMB to implement an electronic version of this form.
  Inventory as of this Action Requested Previously Approved
02/29/2020 36 Months From Approved 03/31/2017
23,000 0 10,000
17,250 0 7,500
0 0 0

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.

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

Not associated with rulemaking

  81 FR 39291 06/16/2016
81 FR 63504 09/15/2016
No

1
IC Title Form No. Form Name
Health History Form (PC 1789) PC-1789 Health History Form

  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 23,000 10,000 0 13,000 0 0
Annual Time Burden (Hours) 17,250 7,500 0 9,750 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This revised Health History Form which replaces the current Health History Form will result in most Applicants answering significantly fewer questions than they would with the current Health History Form. Applicants will gain access to the Health History Form via a secure online portal. The link to the portal will be sent to applicants via email. The Peace Corps anticipates that most Applicants will complete the Health History Form online and that only those few with no electronic access (expected to be no more than 10 Applicants a year) will submit a paper version.

$100,000
No
No
No
No
No
Uncollected
Monique Harris 202 692-2167 [email protected]

  Yes
 
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.
12/20/2016


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