Individual Specific Medical Evaluation Forms (15)

Forms and Documents

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

IC Document Collections

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

ICR Details

OMB Control No:	ICR Reference No: 202407-0420-001
Status: Received in OIRA	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	Date Submitted to OIRA: 07/26/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	30,473	0
Time Burden (Hours)	46,168	0
Cost Burden (Dollars)	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

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

	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	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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