Peace Corps Health History Form

ICR 202011-0420-006

OMB: 0420-0510

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2017-02-10
Supplementary Document
2017-02-10
Supplementary Document
2012-07-12
Supporting Statement A
2017-02-10
Supplementary Document
2011-06-21
IC Document Collections
IC ID
Document
Title
Status
200891 Modified
ICR Details
0420-0510 202011-0420-006
Received in OIRA 201612-0420-002
PEACE PC-1789
Peace Corps Health History Form
Reinstatement without change of a previously approved collection   Yes
Regular 11/17/2020
  Requested Previously Approved
36 Months From Approved
23,000 0
17,250 0
543,720 0

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.

US Code: 22 USC 2504 Name of Law: Peace Corps Act
  
None

Not associated with rulemaking

  85 FR 52386 08/25/2020
85 FR 70207 11/04/2020
No

1
IC Title Form No. Form Name
Health History Form (PC 1789) PC-1789 Health History Form

  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
No
No

$281,875
No
    Yes
    Yes
No
No
No
No
Virginia Burke 202 692-1887 [email protected]

  Yes
  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.
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/17/2020


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