Peace Corps
Office of Health Services
Durable Medical Equipment and Other Devices form
OMB Control Number 0420-0550
Supporting Statement
General instructions
The supporting statement must be prepared in the format described below. If an item in applicable, use “N/A” and provide a brief explanation.
Section A: Justification
Circumstances that make the collection of information necessary.
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).
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 review of an Applicant’s past medical history is an essential first step to determine their suitability for service in Peace Corps.
All applicants to the Peace Corps must have a medical clearance that will determine their ability to serve in a particular country.
The Durable Medical Equipment and Other Devices Form will be used to determine the type of environmental and/or medical support (e.g., reliable electricity, equipment maintenance/replacement, servicing, and warranty coverage) that may be needed to manage the Applicant’s medical condition, such as C-pap machine.
By whom, how, and for what purpose the information is to be used.
The information in these forms 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. If it is determined that the Applicant has a reasonable chance of performing the essential assignment functions and completing a tour of service, the forms will also be used to establish the level of medical and other support, if any, that may be required to reasonably accommodate the Applicant. The information in these forms are used as a baseline assessment for the Peace Corps Medical Officers overseas who are responsible for the Volunteer’s medical care.
Consideration of the use of improved information technology.
The Peace Corps is upgrading the medical component of the electronic application process as part of a larger quality improvement project. Applicants will gain access to the Durable Medical Equipment and Other Devices form via a secure online portal. Applicants will have to download the form 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 forms electronically and that only those with no electronic access will submit a paper version.
Efforts to identify duplication. Why similar information cannot be used.
There is no similar information available to the Peace Corps. This form will be the only agency forms that collect this particular information.
5. Methods to minimize the burden to small business if involved.
This collection does not impact small business or other small entities.
Consequences to the Federal program if collection were conducted less frequently.
The Peace Corps needs the Durable Medical Equipment and Other Devices Form as part of the process of determining 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 and, if so, what accommodation may be needed. If the Peace Corps lacked the medical information obtained during the medical screening process, the Peace Corps would be unable to conduct the assessment.
7. Explain any special circumstances that would cause the information collection to be conducted in a manner inconsistent with guidelines.
There are no special circumstances. Collection will be conducted consistent with 5 C.F.R. 1320.6 guidelines.
8. Consultation.
The agency’s 60-day notice was published in the Federal Register on March 7, 2016, 81FR 11844. No public comments were received during the 60-day period. The 30-Day notice was published September 15, 2016, 81 FR 63506. No public comments were received during the 30-day period.
9. Explain any decision to provide any payment or gift to respondents.
No payment or gift is provided to Applicants applying for Peace Corps service. However, under 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.” 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. This reimbursement is subject to overall limits and may not cover all costs incurred by the Applicant in connection with the medical evaluation. As there are different requirements for medical evaluations based on gender and age, the reimbursement limits vary based on those factors:
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. Describe any assurance of confidentiality provided to respondents.
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. Additional justification for any questions of a sensitive nature.
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 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. Peace Corps Volunteers serve in countries that have a different healthcare infrastructure than that found in the United States. Therefore, it is essential to fully understand each Applicant’s complete medical history, treatments and response to treatment, as well as a baseline evaluation of all conditions. 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 reporting and recordkeeping hour and cost burdens of the collection of information.
Based on the number of applicants in previous years who reported a medical condition requiring a medical device, it is estimated that 400 Applicants will be required to submit Durable Medical Equipment and Other Devices Form. It is estimated that the minimum time associated with the Applicant collection, review and uploading the form to be15 minutes.
The estimate of total annual hour burden to all Applicants submitting this form is 100 hour (400 Applicants x 15 minutes). It is estimated that the total annual hour burden associated with the physician review to be 67 hours (400 Applicants x 10 minutes).
New college graduates are the primary applicant population. It is estimated that 400 Applicants will be required to complete this form and return it to the Peace Corps. The fee scale for this population is FP-07-01 ($35,718 annually or $17.00/hour). For 15 minutes of time to complete this form, the estimated cost would be $1,700 annually
13. Estimates of annualized capital and start-up costs.
The estimate of total annual cost burden to Applicant respondents resulting from collection of the information in this form is the total costs of all medical exams that go beyond 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. Estimates of annualized Federal Government 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.
It is estimated that 400 Applicants will be required to complete this form and return it to the Peace Corps. It is expected that it will take a nurse approximately 5 minutes to review the information. It does not require consultation with a physician. The estimated cost for nurse review is $1,533 (400 Applicants x 5 minutes x $46/hr).
15. Explanation of change in burden.
There are no changes to report.
16. Information collections data planned to be published for statistical use.
This information will not be quantified or published.
17. Explanation for seeking not to display the expiration date for OMB approval of the information collection.
The Agency is not seeking approval to conceal or omit the expiration date for OMB approval of the information collected.
18. Exception to the certification statement.
The agency is able to certify compliance with all provisions under Item 19 of OMB Form 83-I.
STOP HERE!
You do not need to complete Section B if you are not using statistical methods. However, you should be prepared to justify a decision not to use statistical methods in any case where such methods might reduce burden or improve accuracy of results.
SEE NEXT PAGE FOR SECTION B. GO!
If you checked “Does this ICR contain surveys, censuses or employ statistical method” on the OMB 83-I, the following questions should be answered. Note if any of the methods listed below do not apply to the proposed information collection please note “N/A” and provide a brief explanation.
B: Collection of Information Employing Statistical Methods
1. Respondent universe and sampling methods.
Describe (including a numerical estimate) the potential respondent universe and any sampling or other respondent selection methods to be used. Data on the number of entities (e.g., establishments, State and local government units, households, or persons) in the universe covered by the collection and in the corresponding sample are to be provided in tabular form for the universe as a whole and for each of the strata in the proposed sample. Indicate expected response rates for the collection as a whole. If the collection had been conducted previously, include the actual response rate achieved during the last collection.
2. Procedures for the collection of information.
Describe the procedures for the collection of information including:
* Statistical methodology for stratification and sample selection,
* Estimation procedure,
* Degree of accuracy needed for the purpose described in the justification,
* Unusual problems requiring specialized sampling procedures, and
* Any use of periodic (less frequent than annual) data collection cycles to reduce burden.
3. Methods to maximize responses rates and deal with nonresponse.
Describe methods to maximize response rates and to deal with issues of non-response. The accuracy and reliability of information collected must be shown to be adequate for intended uses. For collections based on sampling, a special justification must be provided for any collection that will not yield "reliable" data that can be generalized to the universe studied.
4. Tests of procedures or methods to be undertaken.
Describe any tests of procedures or methods to be undertaken. Testing is encouraged as an effective means of refining collections of information to minimize burden and improve utility. Tests must be approved if they call for answers to identical questions from 10 or more respondents. A proposed test or set of test may be submitted for approval separately or in combination with the main collection of information.
Individuals consulted on statistical aspects and individuals collecting and/or analyzing data.
Provide the name and telephone number of individuals consulted on statistical aspects of the design and the name of the agency unit, contractor(s), grantee(s), or other person(s) who will actually collect and/or analyze the information for the agency.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Peace Corps – Office of Volunteer Recruitment and Selection |
| Author | nfull |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |