Individual Specific Medical Evaluation Forms (15)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form PC-262-14 Mental Health Treatment and Summary	Form and Instruction	Modified	Available
Form PC-262-16 Required Peace Corps Immunization Documentation Form	Form and Instruction	Unchanged	Available
Form PC-262-6 Substance-Related and Addictive Disorders Current Evaluation Form	Form and Instruction	Unchanged	Available
Form PC-262-15 Functional Abilities Evaluation Form	Form and Instruction	Unchanged	Available
Form PC-262-13 Transfer of Care form	Form and Instruction	Unchanged	Available
Form PC-OMS-116 Prescription for Eyeglassess	Form and Instruction	Unchanged	Available
Form PC-262-10 Insulin Dependent Diabetic Supplemental Documentation Form	Form and Instruction	Unchanged	Available
Form PC-262-12 Reactive Tuberculin Test Evaluation Form	Form and Instruction	Unchanged	Available
Form PC-262-7 ECG/EKG Form	Form and Instruction	Unchanged	Available
Form PC-262-9 Colon Cancer Screening Form	Form and Instruction	Unchanged	Available
Form PC-262-11 Cervical Cancer Screening Form	Form and Instruction	Unchanged	Available
Form PC-355-2 Mammogram Waiver Form	Form and Instruction	Unchanged	Available
Form PC-262-8 Eating Disorder Treatment Summary Form	Form and Instruction	Unchanged	Available
Form PC-262-3 Diabetes Evaluation Form	Form and Instruction	Unchanged	Available
Form PC-262-2 Asthma Evaluation Form	Form and Instruction	Unchanged	Available
Justification for revised Mental Health form.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2018-10-10	Available
0420-0550 Supporting Statement.docx	Supporting Statement A	Uploaded 2017-02-07	Available
PC-17.pdf	Supplementary Document	Uploaded 2012-07-12	Available

IC Document Collections

Information collection document groups

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

ICR Details

OMB Control No: 0420-0550	ICR Reference No: 201808-0420-004
Status: Historical Active	Previous ICR Reference No: 201611-0420-001
Agency/Subagency: PEACE	Agency Tracking No:
Title: Individual Specific Medical Evaluation Forms (15)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/02/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/10/2018
Terms of Clearance:

table that charts list comparision

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

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

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Authorizing Statute(s): US Code: 22 USC 2504 Name of Law: Peace Corps Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 81179	11/17/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 9402	02/06/2017
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	18,498	18,498	0	0	0	0
Annual Time Burden (Hours)	19,037	19,037	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

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

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Annual Cost to Federal Government: $440,661

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/10/2018

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