SUPPORTING STATEMENT FOR
PHS-6355 Report of Dental Examination of Applicants to the Commissioned Corps of the Public Health Service
PHS-6379 Supplemental Medical History Record Required of Applicants to the
Public Health Service Commissioned Corps
(Note: The following six questionnaires are online worksheets that are generated based on ‘Yes’ answers on form DoD 2807-1 (Report of Medical History) and DoD 2808 (Report of Medical Examination):
Form PHS-7053 Allergies Questionnaire
Form PHS-7054 Head Injury Questionnaire
Form PHS-7055 Injury Questionnaire
Form PHS-7056 Headache Questionnaire
Form PHS-7057 GYN Questionnaire
Form PHS-7061 Owestry Low Back Questionnaire
AND SUPPORTING REGULATIONS
CONTAINED IN 42 CFR 21.22 AND 21.34
Background
Pursuant to the Paperwork Reduction Act of 1995, the Division of Commissioned Corps Personnel and Readiness (DCCPR), Office of the Secretary, Department of Health and Human Services (HHS), requests that the Office of Management and Budget (OMB) reinstate with changes the forms listed above for use in determining the medical qualifications of applicants to the Commissioned Corps of the U.S. Public Health Service (Corps). Applicants to the Corps must meet the Corps’ medical standards for appointment.
A. Justification
Need and Legal Basis
The principal purpose for collecting the information is to permit HHS to determine medical eligibility for appointment of applicants into the Corps. The Corps is one of the seven Uniformed Services of the United States (37 U.S.C. 101(3)), and appointments in the Corps are made pursuant to 42 U.S.C. 204 et seq. and 42 CFR 21.58. Specifically, these forms are used to evaluate the medical suitability of applicants on the basis of the Corps’ medical accession standards and policy.
Note: On July 24, 2003, the Secretary of HHS delegated the authorities necessary to administer the Corps to the Assistant Secretary for Health. This delegation may have an affect wherever the Surgeon General is cited in this document.
There are two sections of Corps regulations (see Tab C) relevant to the application process. They are 42 CFR 21.22 and 21.34. Section 42 CFR 21.22 is nonspecific in that it requires applicants to submit applications on such forms as the Surgeon General may prescribe. This nonspecific language does not require OMB approval. However, clearance for the language in 42 CFR 21.34 is sought since it requires certification by the applicant of his/her health status. Previous to this supporting statement, no additional response burden was required by this regulation because the medical certifications are performed on Department of Defense (DoD) forms included in the application process and the response burden is accounted for therein (see Tab D). The DoD forms are accompanied by a HHS Privacy Act Statement.
DCCPR is requesting reinstatement,with changes, of the PHS forms listed in this document. The PHS forms requiring OMB approval are:
PHS-6355 Report of Dental Examination of Applicants to the Commissioned Corps of the Public Health Service
PHS-6379 Supplemental Medical History Record Required of Applicants to the
Public Health Service Commissioned Corps
The following six questionnaires are worksheets that are generated based on ‘Yes’ answers provided on the DoD Report of Medical History and Report of Medical Examination forms:
PHS-7053 Allergies Questionnaire
PHS-7054 Head Injury Questionnaire
PHS-7055 Injury Questionnaire
PHS-7056 Headache Questionnaire
PHS-7057 GYN Questionnaire
PHS-7061 Owestry Low Back Questionnaire
Applicants to the Corps must submit the information requested in the application process so that a determination can be made about his/her qualifications for appointment as required by law and regulations.
Recruitment and retention is a primary focus of the Corps and efforts are directed toward recruiting entry-level health professionals and attempting to interest them in career service in the Corps.
An individual applying for a commission with the Corps is expected to be medically qualified, currently and in the foreseeable future, to perform the duties of his/her rank and professional category in various climates and work assignments without endangering his/her health or the health of others. Currently, all candidates for appointment to the Corps must undergo a medical examination performed by a physician or healthcare provider, and be found medically qualified prior to appointment.
When completing form DoD 2807-1, Report of Medical History, an applicant will answer questions with a ‘Yes’ or ‘No’ and will receive appropriate additional questionnaires when the Corps requires more information about a particular ‘Yes’ answer. For example, if the applicant answers ‘Yes’ to the following question: “Have any allergies?”in item 13, the applicant will be presented the questions of form PHS-7053, Allergies Questionnaire. Other ‘Yes’ answers will trigger questions as follows:
Item 16, Frequent, severe, or migraine headaches, ties to PHS-7056, Headache Questionnaire.
Item 19, Head injury or skull fracture, ties to PHS-7054, Head Injury Questionnaire.
Item 50, Any bone or joint problem, injuries, surgery or medical treatment, ties to PHS-7055, Injury Questionnaire.
Item 51, Steel pins, plates, or staples in any bones, ties to PHS-7055, Injury Questionnaire.
Item 52, War a bone or joint brace or support, ties to PHS-7055, Injury Questionnaire.
Item 53, Back pain or trouble, ties to PHS-7061, Owestry Low Back Questionnaire.
Item 79, Been treated for a female disorder, painful periods, or cramps, ties to PHS-7057, GYN Questionnaire.
These questionnaires probe more deeply into the applicant’s ‘Yes’ answers, and offer the Medical Evaluations Officer more necessary information in order to make a determination about the applicant’s medical condition.
Please be aware that these PHS forms are based on the following DoD forms:
DD2351, DoDMERB, Report of Medical Examination;
DD2492, Report of Medical History;
Allergies Questionnaire;
Head Injury Questionnaire;
Sports Injury Questionnaire (PHS wishes to use just ‘Injury’ Questionnaire as the title);
Headache Questionnaire;
GYN Questionnaire; and
Owestry Low Back Questionnaire.
Purpose and Use of Information Collection
The Commissioned Corps of the U.S. Public Health Service has a need for the information in order to assess the qualifications of each applicant and make a determination whether the applicant meets the requirements to receive a commission. The information is used to make determinations on candidates/applicants seeking appointment to the Corps to assess their medical suitability. The purpose is to evaluate the medical suitability of applicants on the basis of the Corps’ medical accession standards and policy. The protected information is accessed by appropriate personnel and clinical reviewers. The forms are not disclosed to external entities, other than for uses authorized by law.
If the applicant is appointed, the information collected is stored in a secure environment and becomes part of the officer’s official personnel file. If the applicant is not appointed, the records are securely retained for two years and then destroyed.
If the information was not collected, it would not be possible to evaluate if the applicant is medically qualified for appointment to the Corps. Corps officers are expected to be medically qualified, on appointment and in the foreseeable future, to perform the duties of their rank and category in various climates and work assignments without endangering their health or the health of others.
3. Use of Improved Information Technology
Presently, a paper-based application process is utilized.
Efforts to Identify Duplication of Similar Information
The Corps has its own requirements for appointment so there is no duplication of effort with respect to its application requirements.
Impact on Small Businesses or Other Small Entities
The information collection involves only individuals.
Consequences of Less Frequent Collection of the Information
The application process pertains only to professionals who wish to apply for an appointment to the Corps. If so, the individual must submit the required forms. There is no other method to collect this information, and if the information is not collected, there would be no way to determine eligibility for appointment in the Corps. Medical information must be collected from all candidates in order to properly review and determine medically suitability for appointment. Less frequent collection results in the inability to assess suitability against medical accession standards.
Special Circumstances Relating to the Guidelines of 5 CFR 1320.5
Each applicant must complete the forms in the application process. The applicant completes only one application for the Corps regardless of the number of professional positions for which he/she may have an interest that are located in the HHS Operating Divisions (OPDIVs) / Staff Divisions (STAFFDIVs) as well as non-HHS organizations in which he/she may be interested.
Federal Register Notice/Outside Consultation
A 60-day Federal Register Notice was published in the Federal Register on September 14, 2016, vol. 178, No.111; pp. 63192 (see Tab F). There were/were no public comments.
The medical forms for applicants process pertains only to professionals who wish to apply for appointment in the Corps. Therefore, no public comments will be sought or obtained in excess of the Federal Register notification.
9. Explanation of Any Payment/Gift to Respondents
No payments or gifts are provided to respondents.
10. Assurance of Confidentiality Provided to Respondents
Data will be kept private to the extent allowed by law. Confidentiality of the data collected is provided pursuant to the Privacy Act of 1974 (5 U.S.C. 552a). Arrangements concerning the handling, storage, and disposition of medical information are explained in the Privacy Act System of Notice (09-40-0002, APHS Commissioned Corps Medical Records, HHS/PSC/HRS) published in the Federal Register, Vol. 63, No. 238, page 68596, December 11, 1998 (see Tab C). The methods of collecting and handling the information comply with the Privacy Act of 1974 and OMB Circular A-130, AManagement of Federal Information Resources, Appendix I, AFederal Agency Responsibilities for Maintaining Records About Individuals.
11. Justification for Sensitive Questions
Answers to sensitive medical related questions will allow the Corps to evaluate the medical suitability of applicants based on the Corps’ medical accession standards.
Disclosure of the social security number is mandatory under provisions of the Social Security Act. The number is used as an applicant identifier.
Estimates of Annualized Hour and Cost Burden
The estimated number of respondents for the PHS-6355 is 1,000 annually with each applicant completing a copy of the form. The average amount of time required to complete the form is 1 hour. The estimated number of respondents for the PHS-6379 is 1,000 annually with each applicant completing a copy of the form. The average amount of time required to complete PHS-6379 is thirty minutes. ‘Yes’ answers on the DD-2807 will trigger request for applicants to complete the questionnaires. Not all applicants will be completing all the questionnaire forms and some applicants will complete none of these forms. The average amount of time required to complete each form is included in 12A.
12A. Estimated Annualized Burden Hours
Form Number
|
No. of Respondents |
Response per Respondent |
Average Burden Hour Per Response (within 1 hour) |
Total Burden Hours |
PHS-6355 |
1,000 |
1 |
1 |
1000 |
PHS-6379 |
4,000 |
1 |
30/60 |
2,000 |
PHS-7053 |
800 |
1 |
6/60 |
80 |
PHS-7054 |
1,320 |
1 |
6/60 |
132 |
PHS-7055 |
2,800 |
1 |
7/60 |
327 |
PHS-7056 |
1,600 |
1 |
7/60 |
187 |
PHS-7057 |
600 |
1 |
5/60 |
50 |
PHS-7061 |
2,000 |
1 |
10/60 |
333 |
TOTAL |
|
|
|
4109 |
12B. Annualized Burden Cost
The annualized burden cost to respondents is based on $15 wages per hour per applicant and $82.86 per hour for a Dentist evaluation.
Form Number |
Total Burden Hours |
Hourly Wage Rate |
Total Respondent Costs |
PHS-6355 |
1,000 |
$82.86 |
$82,860.00 |
PHS-6379 |
2000 |
$15.00 |
$30,000.00 |
PHS-7053 |
80 |
$15.00 |
$1,200.00 |
PHS-7054 |
132 |
$15.00 |
$1,980.00 |
PHS-7055 |
327 |
$15.00 |
$4,905.00 |
PHS-7056 |
187 |
$15.00 |
$2,805.00 |
PHS-7057 |
50 |
$15.00 |
$750.00 |
PHS-7061 |
333 |
$15.00 |
$4,995.00 |
TOTAL |
|
|
$129,495.00 |
Capital Costs (Maintenance of Capital Costs)
There are no identified costs associated with collection of the information.
Annualized Cost to the Federal Government
On average, approximately 20 minutes of staff time by one personnel specialist (average grade GS-9/Step 6 $83,480 salaries plus overhead) is used to process applications. At approximately $41.00 per hour, the cost of processing is approximately $13.53 for each application and for 1,000 yearly applications the total is $13,530.00.
On average, approximately 75 minutes of professional staff time is required to review each application. At $130,000.00 (average salary plus overhead), the cost of one professional personnel reviewing applications is $80.00 per application and for 1,000 yearly applications the total is $80,000.00.
The annual cost to the Federal Government for processing applications is estimated to be $93,530.00.
Explanation for Program or Change or Adjustment
The program change included the removal of PHS-7059 (Report of Medical Examination)
and PHS-7060 (Report of Medical History). These forms were replaced with DD 2807-1 (Report of Medical History). As stated previously, no additional response burden was required because the medical certifications are performed on Department of Defense DoD) forms included in the application process and the response burden is accounted for therein. However, the implementation of PHS-6355 (Report of Dental Examination of Applicants to the Commissioned Corps of the Public Health Service) and PHS-6379 (Supplemental Medical History Record Required of Applicants to the Public Health Service Commissioned Corps) increased the response burden hours. The average amount of time required to complete all forms is included in 12A.
Plans for Tabulation and Publication Project Time Schedule
The data collected will not be published for statistical use.
17. Reason(s) Display of OMB Expiration Date Is Inappropriate
The date of expiration of OMB approval will be displayed on each form.
18. Exceptions to Certification for Paperwork Reduction Act Submissions
There are no exceptions.
B. Collection of Information Employing Statistical Methods
Not applicable. The information collected will not be analyzed by employing statistical methodology.
July 29, 2016
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR |
| Author | Roberts, Davonda (Kyle) (OS/OASH/OSG) |
| Last Modified By | Windows User |
| File Modified | 2017-03-03 |
| File Created | 2017-03-03 |