Information Collection

Peace Corps Volunteer Authorization for Examination and/or Treatment

IC 236890 under ICR 202212-1240-002 · OMB 1240-0059.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0059 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-15 Peace Corps Volunteer Authorization for Examination and/or Treatment	Form and Instruction
CA-15 Peace Corps Volunteer Authorization for Examination And/ CA-15 pdf.pdf www.ecomp.dol.gov/	Form and Instruction
CA-15 Peace Corps Volunteer Authorization for Examination And/ CA-15 pdf.pdf www.ecomp.dol.gov/	Form and Instruction

IC Title:

Peace Corps Volunteer Authorization for Examination and/or Treatment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 10.731 20 CFR 10.730

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-15	Peace Corps Volunteer Authorization for Examination And/Or Treatment	CA-15 pdf.pdf	https://www.ecomp.dol.gov/	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 81 FR 47418

Number of Respondents: 252

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	252	0	252
Annual IC Time Burden (Hours)	63	0	63
Annual IC Cost Burden (Dollars)	159	13	146

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.