Peace Corps -- Office of Medical Services
Report of Physical Examination
(PC-OMS-1790S)
OMB Control No. 0420-0549
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 unreasonable 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
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 examination of an Applicant’s medical condition(s) is an essential step to determine their suitability for service in Peace Corps.
All Applicants begin the medical portion of the application process by completing a comprehensive Health History Form, for which the Peace Corps is submitting a concurrent justification dated XXX XX, 2016 (the “Health History Form”), covered under OMB control number 0420-0510. After completion of the Health History Form and after passing a non-health-related assessment, 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, as documented in a Report of Physical Examination which is covered by this Supporting Statement, and any required supplemental medical evaluations (see the Supporting Statement for the Individual Specific Medical Evaluation forms dated XXX XX, 2016), the Peace Corps preservice medical staff performs a comprehensive medical review and final clearance process.
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 assignment and complete a tour of service without unreasonable disruption due to health problems.
2. 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).
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. The Peace Corps is upgrading the medical component of the electronic application process as part of a larger quality improvement project. In conjunction with this project, medical staff has reviewed and revised the medical screening forms including the Health History Form, The Report of Physical Examination, Report of Dental Examination, and the Individual Specific Medical Evaluation Forms. These changes are an effort to:
Reduce time required for an Applicant and their health care providers to manage and complete the medical forms
Reduce the number of medical forms
Clarify content based on the lessons learned from customer feedback.
Applicants will gain access to the physical examination form via a secure online portal. Applicants will have to download the form for their health care provider to complete. The completed form can be scanned and uploaded back into the Applicant’s secure Peace Corps online portal or they can be faxed or mailed to the Peace Corps Office of Medical Services. The Peace Corps anticipates that most Applicants will submit the form electronically and that only those with no electronic access will submit a paper version. Applicant’s health care provider does not have access to the Applicant’s secure Peace Corps online portal therefore unable to complete and sign the Physical Exam form electronically.
4. There is no similar information available to the Peace Corps. This form is the only agency form that collects this particular information concerning an Applicant’s baseline physical examination. The information obtained through the Report of Physical Examination is needed for all Applicants who have accepted an invitation to serve.
5. This information does not have a significant impact on small businesses or other small entities.
6. Under Section 5(e) of the Peace Corps Act, 22 U.S.C. 2504(e), “Applicants for enrollment shall receive such health examinations preparatory to their service … as the President may deem necessary or appropriate.” A complete physical examination is necessary in order to determine if 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 unreasonable disruption due to health problems and, if so, the accommodation that is needed. If the Peace Corps lacked the medical information contained in the Report of Physical Examination, the Peace Corps would be unable to make such a determination. Because all medical information must be current, individuals who apply to become Peace Corps Volunteers more than once may be asked to submit additional Physical Exam forms.
7. There are no special circumstances. Collection will be conducted consistent with 5 C.F.R. 1320.6 guidelines.
8. The FOIA/PA office will submit a notice to the Federal Register.
9. No payment or gift is provided to Applicants applying for Peace Corps service. However, in accordance with the authority provided in 22 U.S.C. 2504(e), the Peace Corps reimburses Applicants for some of the expenses that they incur for medical examinations that they undergo in connection with the Peace Corps Volunteer application process.
Reimbursement is subject to overall limits and may not cover all costs incurred by the Applicant in connection with the medical evaluation. Depending on the age and gender of an Applicant, there are different requirements for evaluation. For example, all women are required to provide Pap exam results and all Applicants who are 50 years of age or older are required to submit results of an electrocardiogram and colon cancer screening. Because there are different requirements for medical evaluations based on gender and age, the reimbursement limits vary based on the factors below:
Females under 50 may be reimbursed up to $165
Females 50 and older may be reimbursed up to $290
Males under 50 may be reimbursed up to $125
Males 50 and older may be reimbursed up to $175
In addition, Applicants are reimbursed only to the extent that they are not otherwise reimbursed by their insurance companies. Peace Corps is seeking Paperwork Reduction Act approval for these forms.
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 assignment and complete a tour of service without unreasonable 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. 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. Estimates of hour burden:
Only an Applicant who has accepted an invitation to serve as a Peace Corps Volunteer will receive the Report of Physical Examination, instructing the Applicant to see a licensed physician and undergo a general medical examination, inclusive of laboratory testing, and to submit the results to the Peace Corps. Based on the number of Volunteers projected to receive invitations to serve in the next year, it is estimated that 5,600 Applicants annually will receive this form. This number may be higher or lower depending on the actual number of Applicants who accept an invitation.
Based on phone interviews with current Peace Corps Applicants undergoing the medical evaluation process, it is estimated that the time associated with the Applicant downloading the form, driving to and from the physician’s office and scanning and uploading, faxing or mailing the completed form will be 45 minutes. This is made up of an average driving time to and from the physician office of 35 minutes and an additional 10 minutes to download the form and to scan and upload, fax or mail the completed form to the Peace Corps. It is estimated that it will take both the Applicant and the physician 45 minutes for the office visit, during which the Applicant will be examined by the physician and the physician will complete the form. The estimate of the total annual hour burden to each Applicant completing the information on this form, inclusive of the time to go to and from the physician, being examined by the physician and waiting for the physician to complete the form and the associated paperwork retrieval and return, is therefore 1 hour 30 minutes. The estimate of the total annual hour burden to each Applicant’s physician completing the information on this form is 45 minutes.
The estimate of total annual hour burden range to all physicians and Applicants completing the information on this form is 4,200 hours of physician time (5,600 Applicants x 45 minutes) and 8,400 hours of Applicant time (5,600 Applicants x 90 minutes).
13. The estimate of total annual cost burden to Applicant respondents resulting from collection of the information in this form is the total cost of the medical examination, including lab tests, that exceeds the maximum Peace Corps reimbursement, which is discussed in response to question 9. The Peace Corps is unable to estimate this overall cost due to the variety of fees that physicians and other health professionals charge and due to the unknown value of insurance reimbursements.
14. Estimated annual cost to the Federal Government. There is no start-up cost associated with these forms as they are part of a larger initiative whose costs have already been fully accounted for with OMB form 0420-0510. The Report of Physical Examination form will not add to those costs.
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. Physicians and mental health professionals are paid at the FS-1 pay scale with a mid-range rate of $69 an hour, which is $87 an hour with benefit costs included.
It is estimated that 5,600 Applicants will be required to submit the Report of Physical Examination to the Peace Corps. It is estimated that it will take a nurse 15 minutes to review the Report of Physical Examination. The nurse review of the Report of Physical Examination does not require consultation with a physician. The estimated cost for nurse review is $257,600 (5,600 Applicants x 15 minutes x $46/hr) .
For those Applicants who become Volunteers, the information in this form will also be used by Peace Corps Medical Officers overseas in providing medical care during the Volunteer’s service. The costs associated with the receipt and review of this information is indeterminate based on the wide range of Peace Corps Medical Officer hourly rates and the time associated with review of the Report of Physical Examination in individual cases. It is understood that this is part of an everyday job requirement for all the Peace Corps Medical Officers in the field and reviewing these forms in no way increases the costs to the Federal Government. If Peace Corps Medical Officer did not have the information in this form, they would have to acquire the information through some other means, which would add to their daily workload.
15. The updated Report of Physical Examination replaces the current Report of Physical Examination used by Peace Corps under control number 0420-0549. These changes are an effort to reduce time required for an Applicants health care provider to complete the physical form.
16. This information will not be quantified or published.
17. 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.
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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | kjordan2 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |