Peace Corps Health History Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form PC-1789 Health History Form (PC 1789)	Form and Instruction	Modified	Missing upstream
Justification for revised DME_Final 1_25_16.docx	Supplementary Document	Uploaded 2017-02-10	Repair queued
DME Form - OMB changes.docx	Supplementary Document	Uploaded 2017-02-10	Missing upstream
PC-17.pdf	Supplementary Document	Uploaded 2012-07-12	Repair queued
2017 HHF Supporting Statement.docx	Supporting Statement A	Uploaded 2017-02-10	Repair queued
22 USC 2504.pdf	Supplementary Document	Uploaded 2011-06-21	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
200891	Health History Form (PC 1789)	Form and Instruction	Modified

ICR Details

OMB Control No: 0420-0510	ICR Reference No: 202011-0420-006
Status: Received in OIRA	Previous ICR Reference No: 201612-0420-002
Agency/Subagency: PEACE	Agency Tracking No: PC-1789
Title: Peace Corps Health History Form
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  Yes
Type of Review Request: Regular	Date Submitted to OIRA: 11/17/2020

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	23,000	0
Time Burden (Hours)	17,250	0
Cost Burden (Dollars)	543,720	0

---

Abstract: All Peace Corps Volunteer applicants must undergo a physical examination prior to service during the application process to ensure good health and be able to serve 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: None

---

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 52386	08/25/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 70207	11/04/2020
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Health History Form (PC 1789)	PC-1789	Health History Form

---

ICR Summary of Burden

table that charts list 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	23,000	0	0	0	0	23,000
Annual Time Burden (Hours)	17,250	0	0	0	0	17,250
Annual Cost Burden (Dollars)	543,720	0	0	543,720	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:

---

Annual Cost to Federal Government: $281,875

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 collected is required for consideration for Peace Corps Volunteer service. The information in the Health History 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 and complete a tour of service without undue disruption due to health problems and, if so, to establish the level of medical and programmatic support, if any, that may be required to reasonably accommodate the Applicant.

Approved RCFs using this ICR

table that charts list of RCF

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

---