Report of Physical Examination

Forms and Documents

Document Name	Status
Form PC-1790S Report of Physical Examination Form and Instruction	Modified
PE Supporting Statement 2016.docx Supporting Statement A	2017-02-07
PC-17.pdf Supplementary Document	2012-07-12

IC Document Collections

IC ID	Document Title	Status
200941	Report of Physical Examination Form and Instruction	Modified

ICR Details

OMB Control No: 0420-0549	ICR Reference No: 202011-0420-004
Status: Received in OIRA	Previous ICR Reference No: 201611-0420-002
Agency/Subagency: PEACE	Agency Tracking No: PC-1790s
Title: Report of Physical Examination
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  Yes
Type of Review Request: Regular	Date Submitted to OIRA: 11/17/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	10,200	0
Time Burden (Hours)	22,950	0
Cost Burden (Dollars)	0	0

---

Abstract: The information contained in 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.

---

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

Citations for New Statutory Requirements: US Code: 24 USC 2504 Name of Law: Peace Corps Law

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 52387	08/25/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 70206	11/04/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Report of Physical Examination	PC-1790S	Physical Examination Form

---

ICR Summary of Burden

	Total Request	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	10,200	0	0	4,600	0	5,600
Annual Time Burden (Hours)	22,950	0	0	14,550	0	8,400
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

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

Burden Reduction Due to:

Short Statement: Previous Year incorrect

---

Annual Cost to Federal Government: $63,750

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? No

---

Common Form ICR:  Yes

Description/Changes for Common Form Usage:  The information in this 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 assignment and complete a tour of service without unreasonable disruption due to health problems and, if so, to establish the level of medical and other support, if any, that may be required to reasonably accommodate the Applicant. The information in this form is also 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 this form 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).

Approved RCFs using this ICR

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:

(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: 11/17/2020

---