Individual Specific Medical Evaluation Forms (15)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form PC-262-16 Vaccination Requirement Form	Form and Instruction	New	Repair queued
Form PC-262-16 Required Peace Corps Immunizations Form	Form and Instruction	New	Repair queued
Form PC-OMS-116 Prescription for Eyeglasses Form	Form and Instruction	New	Repair queued
Form PC-OMS-116 Prescription for Eyeglasses Form	Form and Instruction	New	Repair queued
Form PC-262-10 Insulin Dependent Supplemental Documentation Form	Form and Instruction	New	Available
Form PC-262-10 Insulin Dependent Supplemental Documentation Form	Form and Instruction	New	Repair queued
Form PC-262-12 Reactive Tuberculin Test Evaluation Form	Form and Instruction	New	Repair queued
Form PC-262-12 Reactive Tuberculin Test Evaluation Form	Form and Instruction	New	Repair queued
Form PC-262-7 Electrocardiogram (ECG/EKG) Form	Form and Instruction	New	Repair queued
Form PC-262-7 ECG Form	Form and Instruction	New	Repair queued
Form PC-262-9 Colon Cancer Screening Form	Form and Instruction	New	Repair queued
Form PC-262-9 Colon Cancer Screening Form	Form and Instruction	New	Repair queued
Form PC-262-11 Cervical Cancer Screening Form	Form and Instruction	New	Repair queued
Form PC-262-11 Cervical Cancer Screening Form	Form and Instruction	New	Repair queued
Form PC-355-2 Mammogram Waiver Form	Form and Instruction	New	Repair queued
Form PC-355-2 Mammogram Waiver Form	Form and Instruction	New	Repair queued
Form PC-262-6 Substance-Related and Addictive Disorders Current Evaluation Form	Form and Instruction	New	Repair queued
Form PC-262-6 Substance-Related and Addictive Disorders Current Evaluation Form	Form and Instruction	New	Repair queued
Form PC-262-8 Eating Disorder Treatment	Form and Instruction	New	Repair queued
Form PC-262-8 Eating Disorder Treatment Summary Form	Form and Instruction	New	Repair queued
Form PC-262-15 Functional Abilities Evaluation Form	Form and Instruction	New	Available
Form PC-262-15 Functional Abilities Evaluation Form	Form and Instruction	New	Repair queued
Form PC-262-14 Mental Health Current Evaluation and Treatment Summary Form	Form and Instruction	New	Repair queued
Form PC-262-14 Mental Health Current Evaluation and Treatment Summary	Form and Instruction	New	Repair queued
Form PC-262-13 Transfer of Care	Form and Instruction	New	Repair queued
Form PC-262-13 Transfer of Care	Form and Instruction	New	Repair queued
Form PC-262-3 Diabetes Evaluation Form	Form and Instruction	New	Repair queued
Form PC-262-3 Diabetes Diagnosis Form	Form and Instruction	New	Repair queued
Form PC-262-2 Asthma Evaluation Form	Form and Instruction	New	Repair queued
Form PC-262-2 Asthma Evaluation Form	Form and Instruction	New	Repair queued
Justification for revised Mental Health form.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-07-26	Repair queued
PC-17.pdf	Supplementary Document	Uploaded 2024-07-26	Repair queued
Collection_Supporting Statement A 0420-0550 15 forms.docx	Supporting Statement A	Uploaded 2024-07-26	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
269653	Required Peace Corps Immunizations Form	Form and Instruction	New	Vaccination Requirement Form
269653	Required Peace Corps Immunizations Form	Form and Instruction	New
269652	Prescription for Eyeglasses Form	Form and Instruction	New	Prescription for Eyeglasses Form
269652	Prescription for Eyeglasses Form	Form and Instruction	New
269651	Insulin Dependent Supplemental Documentation Form	Form and Instruction	New	Insulin Dependent Supplemental Documentation Form
269651	Insulin Dependent Supplemental Documentation Form	Form and Instruction	New
269650	Reactive Tuberculin Test Evaluation Form	Form and Instruction	New	Reactive Tuberculin Test Evaluation Form
269650	Reactive Tuberculin Test Evaluation Form	Form and Instruction	New
269648	ECG Form	Form and Instruction	New	Electrocardiogram (ECG/EKG) Form
269648	ECG Form	Form and Instruction	New
269647	Colon Cancer Screening Form	Form and Instruction	New	Colon Cancer Screening Form
269647	Colon Cancer Screening Form	Form and Instruction	New
269646	Cervical Cancer Screening Form	Form and Instruction	New	Cervical Cancer Screening Form
269646	Cervical Cancer Screening Form	Form and Instruction	New
269645	Mammogram Waiver Form	Form and Instruction	New	Mammogram Waiver Form
269645	Mammogram Waiver Form	Form and Instruction	New
269644	Substance-Related and Addictive Disorders Current Evaluation Form	Form and Instruction	New	Substance-Related and Addictive Disorders Current Evaluation Form
269644	Substance-Related and Addictive Disorders Current Evaluation Form	Form and Instruction	New
269643	Eating Disorder Treatment Summary Form	Form and Instruction	New	Eating Disorder Treatment
269643	Eating Disorder Treatment Summary Form	Form and Instruction	New
269642	Functional Abilities Evaluation Form	Form and Instruction	New	Functional Abilities Evaluation Form
269642	Functional Abilities Evaluation Form	Form and Instruction	New
269641	Mental Health Current Evaluation and Treatment Summary	Form and Instruction	New	Mental Health Current Evaluation and Treatment Summary Form
269641	Mental Health Current Evaluation and Treatment Summary	Form and Instruction	New
269640	Transfer of Care	Form and Instruction	New	Transfer of Care
269640	Transfer of Care	Form and Instruction	New
269639	Diabetes Diagnosis Form	Form and Instruction	New	Diabetes Evaluation Form
269639	Diabetes Diagnosis Form	Form and Instruction	New
269638	Asthma Evaluation Form	Form and Instruction	New	Asthma Evaluation Form
269638	Asthma Evaluation Form	Form and Instruction	New

ICR Details

OMB Control No: 0420-0578	ICR Reference No: 202407-0420-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: PEACE	Agency Tracking No:
Title: Individual Specific Medical Evaluation Forms (15)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/29/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/26/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2029	36 Months From Approved
Responses	30,473	0	0
Time Burden (Hours)	46,168	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The 15 forms listed may be sent to an individual Applicant at one of the following times in the medical review process: (1) after the Applicant completes the Health History Form and receives a nomination; (2) after a Peace Corps nurse reviews the Applicant's Health History Form and any completed forms previously requested; or (3) at the time of the Applicant's physical examination. The results of the physical examination and the information contained in the specific evaluation forms will be used to make an individualized determination as to whether an Applicant for Volunteer service 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.

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Authorizing Statute(s): US Code: 22 USC 2504 Name of Law: Peace Corps Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 25286	04/10/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 51559	06/18/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Asthma Evaluation Form	PC-262-2	Asthma Evaluation Form
Cervical Cancer Screening Form	PC-262-11	Cervical Cancer Screening Form
Colon Cancer Screening Form	PC-262-9	Colon Cancer Screening Form
Diabetes Diagnosis Form	PC-262-3	Diabetes Evaluation Form
ECG Form	PC-262-7	Electrocardiogram (ECG/EKG) Form
Eating Disorder Treatment Summary Form	PC-262-8	Eating Disorder Treatment
Functional Abilities Evaluation Form	PC-262-15	Functional Abilities Evaluation Form
Insulin Dependent Supplemental Documentation Form	PC-262-10	Insulin Dependent Supplemental Documentation Form
Mammogram Waiver Form	PC-355-2	Mammogram Waiver Form
Mental Health Current Evaluation and Treatment Summary	PC-262-14	Mental Health Current Evaluation and Treatment Summary Form
Prescription for Eyeglasses Form	PC-OMS-116	Prescription for Eyeglasses Form
Reactive Tuberculin Test Evaluation Form	PC-262-12	Reactive Tuberculin Test Evaluation Form
Required Peace Corps Immunizations Form	PC-262-16	Vaccination Requirement Form
Substance-Related and Addictive Disorders Current Evaluation Form	PC-262-6	Substance-Related and Addictive Disorders Current Evaluation Form
Transfer of Care	PC-262-13	Transfer of Care

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	30,473	0	0	30,473	0	0
Annual Time Burden (Hours)	46,168	0	0	46,168	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The Peace Corps is returning to full volunteer service after the COVID pandemic resulted in full evacuation of all volunteers. There are more than 2900 volunteers on active service in 59 countries. As more countries issue invitations for service, we expect the numbers of volunteers to increase.

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Annual Cost to Federal Government: $627,131

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

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Common Form ICR:  No

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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: 07/26/2024

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