Peace Corps -- Office of Medical Services
Report of Dental Exam (PC-1790 Dental)
OMB Control No. 0420-0546
1. The Peace Corps Act states that “Applicants for enrollment shall receive such health examinations preparatory to their service… as the President may deem necessary or appropriate.” See 22 U.S.C. 2504(e). Peace Corps has determined that all Applicants “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… without unreasonable disruption due to health problems.” See 22 C.F.R. 305.2(c). To ensure that Volunteers meet this medical eligibility requirement, all Applicants for service must undergo physical and dental examination prior to Volunteer service “to provide the information needed for clearance, to serve as a reference for any future Volunteer medical clearance, and to serve as a reference for any future Volunteer disability claims.” See Peace Corp Manual Section 262.4.
2. The Peace Corps Office of Medical Services is responsible for the collection of Applicant dental information, using the Report of Dental Exam “Dental Exam” form. The Dental Exam form is completed by the Applicant’s examining dentist. The results of the examinations are used to ensure that Applicants for Volunteer service will, with reasonable accommodation, be able to serve in the Peace Corps without jeopardizing their health.
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 have 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 being made in an effort to:
Reduce the 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 access the Dental Examination form via a secure online portal. Applicants will download the form for their dentist to complete. The Dental Exam form must be personally completed and signed by the examining dentist. The completed form can be scanned and uploaded into the Applicant’s secure Peace Corps online portal, faxed, or mailed to the Peace Corps Office of Medical Services.
4. The Report of Dental Exam form is the only agency form that collects information concerning an Applicant’s dental history and existing conditions from the Applicant’s examining dentist.
5. This information does not have significant impact on small business 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 dental examination is necessary in order to determine if an Applicant will, with reasonable accommodation, be able to perform essential functions of the Peace Corps Volunteer assignment 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 Dental Examination, the Peace Corps would be unable to make such a determination. The Peace Corps Act requires that Volunteers receive health examinations prior to their service. The information collected is, therefore, required for consideration for Peace Corps Volunteer service.
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 respondents. However, the Peace Corps does reimburse Applicants who are not otherwise reimbursed by their insurance companies. Applicants may be reimbursed up to $60 for dental exams.
10. Applicants are informed that the medical information they provide will be maintained in accordance with the Privacy Act (5 U.S.C. 552a). Specifically, 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). Applicants also sign an Authorization permitting the use and disclosure of medical information within the Peace Corps to Peace Corps staff with a specific need to know designation.
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 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 the hour burden:
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Dental Exam Form |
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5600 |
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135 minutes |
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One time |
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12600 hours |
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 dentist’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 dentist 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 dentist 45 minutes for the office visit, during which the Applicant will be examined by the dentist and the dentist 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 dentist completing the information on this form is 45 minutes.
The estimate of total annual hour burden range to all dentist and Applicants completing the information on this form is 4,200 hours of dentist time (5,600 Applicants x 45 minutes) and 8,400 hours of Applicant time (5,600 Applicants x 90 minutes).
13. Peace Corps is unable to accurately estimate how much of this expense will be borne by Applicants but we estimate the cost to be approximately $1,008,000 for the Report of Dental Evaluation. We calculate this figure based on an estimated cost of $180.00 per Applicant times 5600 Applicants per year. Cost per Applicant is $180.00 ($80.00 for the dental examination and $160.00 for the associated dental x-rays, less the Peace Corps Cost Share reimbursement of $60.00). These cost estimates do not take into account Applicants with health insurance and who do not request cost share reimbursement.
14. Estimated annual cost to the Federal Government:
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Responses are returned by postage paid reply mail, Peace Corps provided Federal Express mailers or electronically via the Peace Corps web site.
15. The updated Report of Dental Examination replaces the current Report of Dental Examination used by Peace Corps under control number0420-0546. These changes are an effort to clarify content based on lessons learned from customer feedback and to reduce time required for dental providers to complete the dental examination.
16. Not applicable. This information will not be quantified or published.
17. Not applicable. Peace Corps will display the expiration date for OMB approval of the information collection.
18. Not applicable. There are no exceptions to the certification statement identified in Item 19 of OMB Form 83-1.
This collection of information does not employ statistical methods.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Peace Corps -- Office of Medical Services |
| Author | Caroline Allen |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |