Supporting Statement

Peace Corps -- Office of Medical Services

Health History Form (PC-1789)

OMB Approval Number 0420-0510

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 undue 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 also 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

The Health History Form is used to document the medical history of each Applicant. It is a self-report of pre-existing medical conditions and is used to help determine 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 undue disruption due to health problems.

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 suitability for service in the Peace Corps.

All Applicants will begin the medical portion of the application process by completing the Health History Form covered by this Supporting Statement. The Health History Form will be completed online in an interactive process in which only questions relevant to each Applicant’s medical history (based on responses to previous questions) are presented. 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 and any required supplemental medical, 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 information contained in the Applicants Health History Form and the Report of Physical Examination 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.

2. The information in the Health History Form 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 and complete a tour of service without undue disruption due to health problems and, if so, to establish the level of medical and programmatic support, if any, that may be required to reasonably accommodate the Applicant. If it is clear that there is no reasonable accommodation that will enable the Applicant to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems, the Applicant will be medically disqualified early in the application process, thus eliminating the need for the Applicant to undergo a long and costly full medical evaluation process. If the Applicant is preliminarily found to satisfy the Peace Corps’ medical status eligibility requirements, the information in this form will be used to determine what reasonable accommodations are required, including identifying the Peace Corps posts that can support the Applicant’s particular medical needs. For those Applicants invited to serve, this form is 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. 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.

4. The HHF is the agency’s only form that collects information about an Applicant’s medical history and existing medical conditions.

5. This information does not have significant impact on small businesses or other small entities.

6. The Peace Corps needs the Applicant’s self-reported medical history information in the Health History Form as part of the process of determining if 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 undue disruption due to health problems and, if so, what, if any, accommodation may be needed. Based on the information reported on the Health History Form, the Peace Corps may determine that there is a need for additional medical records or a health professional consultation, if the Applicant has self-identified a medical condition of significant severity. If the Peace Corps lacked the medical information obtained from the Health History Form, the Peace Corps would be unable to make a medical clearance determination.

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

8. The agency’s notice was published in the Federal Register on January 27, 2012, 77 FR 4375. No public comments were received during the 60-day period.

9. No payment or gift is provided to Applicants applying for Peace Corps service.

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 undue 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. Estimate of hour burden:

Health History Form responses, in almost all cases, is entered electronically via the Peace Corps website. It is estimated that it will take the average Applicant 45 minutes to complete the Health History Form, although this will vary from Applicant to Applicant depending on the Applicant’s health history. It is estimated, based on the number of Applicants who applied last year, that 23,000 Applicants will complete a Health History Form each year. The estimate of total annual hour burden to all Applicants completing the information on the Health History Form is 17,250 hours (23,000 Applicants x 45 minutes).

13. There is no anticipated cost to an Applicant resulting from collection of the information in the Health History Form.

14. The Health History Form is the medical component of the business of processing applications for Peace Corps Volunteer service. This revision of the Health History Form includes a large IT system upgrade. The cost for the medical screening system, which includes the Health History Form and the distribution and review of all associated medical forms, is $800,000 in one-time upgrade costs and $100,000 in annual maintenance.

A Pre-service Nurse reviews the Health History Form after an Applicant is invited. Based on invitation projections, it is estimated that 5,600 Applicants will be invited and will have their Health History Forms reviewed by a Pre-service Nurse. 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.

The amount of time that it will take a nurse to review an Applicant’s Health History Form will vary from Applicant to Applicant depending on the nature of the Applicant’s medical history. Based on past experience, Applicants with limited or no medical history will require only a cursory review of the information taking approximately 5 minutes, while Applicants with more complicated medical history will require a longer review taking up to 30 minutes. The estimated annual cost for nurse review of all Health History Form is therefore between $4,293 (1,120 Applicants x 5 minutes x $46/hr) and $103,040 (4,480 Applicants x 30 minutes x $46/hr).

15. The new Health History Form will be implemented through an automated online process.

16. This information will not be quantified or published.

17. Not applicable. 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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