Non-substantive Change Justification

Mental Health Evaluation and Treatment Summary

OMB Control Number 0420-0550

Justification for No Material/Nonsubstantive Change

The Peace Corps Office of Health Services proposes to make changes to the Peace Corps Mental Health Evaluation and Treatment Summary, OMB Control Number: 0420-0550, submitted for OMB approval on 12/20/2016.

The changes are intended to clarify the instructions and simplify the questions and are based on the feedback that mental health providers do not understand what the Peace Corps is asking for, which results in incomplete or inadequate submission of information. Here is a summary of the changes:

1. Rename form

Previous: Mental Health Current Evaluation and Treatment Summary Form

New: Mental Health Evaluation and Treatment Summary

2. Content edits

1. Reduce wordiness of cover page

2. Improve instructions for the provider; add instructions for how to submit the form directly to Peace Corps via confidential fax and how to contact Peace Corps with questions

3. The goal of the first page of the form is to establish how well the provider knows the patient, if treatment is ongoing, and treatment modality. Peace Corps staff are frequently unable to determine this information, so page one will be reworded and reformatted to make this collection of information clearer.

4. Instructions for completing the psychotropic medications section aren’t resulting in the desired outcome of the prescribing clinician completing the section. We have learned that it is unrealistic that the provider completing form (in cases when they aren’t the prescriber) to coordinate with the prescribing clinician. Instructions and signature line in this section will be removed.

5. Remove redundant instructions for supporting reports and documentation.

6. Shorten the sentences in the Clinical Assessment sections to reduce redundancies.

3. Formatting edits

1. Move applicant name and DOB from the cover page to the first page of the form, to avoid having the cover page unnecessarily returned to the Peace Corps.

2. Move provider’s contact information to the end of the form.

3. Remove unnecessary section headers throughout the form.

4. Reorder the sections on page one, grouping mental health diagnosis and symptoms together, followed by general disorders. Provide examples for all three so providers know what the Peace Corps is looking for.

5. Remove lines for writing on throughout, allowing for the provider to write in the blank space provided.

6. Move content from tables into question format, allowing the provider more space to write without the confines of a table.