Supporting Statement A 0420-0546 Report of Dental Examination

Peace Corps -- Office of Medical Services

Report of Dental Examination Form (PC-1790) - OMB Control No. 0420-0546

SUPPORTING STATEMENT

Section A. Justification

1. The Peace Corps Act states that “[t]he President may enroll in the Peace Corps for service abroad qualified citizens and nationals of the United States (referred to in this Act as “volunteers”). The terms and conditions of the enrollment … of volunteers shall be exclusively those set forth in this Act and those consistent therewith which the President may prescribe …” 22 U.S.C. 2504(a). Eligibility requirements for the Peace Corps have been prescribed in 22 C.F.R. Part 305. Among those eligibility requirements is one relating to medical status. An Applicant “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 for which he or she is otherwise eligible and be able to complete an agreed upon tour of service, ordinarily two years, without unreasonable disruption due to health problems.” 22 C.F.R. 305.2(c). All Applicants for service must undergo a physical examination and a dental evaluation prior to Volunteer service to determine if they meet this medical status eligibility requirement. In addition, under 22 U.S.C. 2504(e), the Peace Corps provides medical care to Volunteers during their service and the information collected will be used in connection with medical care and treatment during Peace Corps service for Applicants who become Volunteers. Finally, the information collected may serve as a point of reference for any potential future Volunteer worker’s compensation claims.¹

Volunteers serve in 55 developing countries where western-style healthcare is often not available. Volunteers are placed in remote locations where they may suffer hardship because they have no access to running water and/or electricity. They also may be placed in locations with extreme environmental conditions related to cold, heat or high altitude and they may be exposed to diseases not generally found in the U.S. Volunteers may be placed many hours from the Peace Corps medical office and not have easy access to a health care provider. Therefore, a thorough review of an Applicant’s past medical history is an essential first step to determine their suitability for service in Peace Corps.

All Applicants will begin the medical part of the application process by completing a comprehensive Health History Form, covered under OMB control number 0420-0510. After completion of the Health History Form and after passing preliminary non-health-related assessments, the Applicant will be “invited” to a country specific program that has been preliminarily identified as having the medical resources to meet their health care needs, if any. After an Applicant submits a complete physical examination, as documented in a Report of Physical Examination (covered under OMB control number 0420-0549), and any required supplemental medical evaluations covered by this supporting statement, the Peace Corps preservice medical staff performs a comprehensive medical review which will result in a final determination regarding their medical clearance for Peace Corps service.

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 has 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 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.

The form covered by this Supporting Statement 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 invitation; (2) after a Peace Corps nurse reviews the Applicant’s Health History Form and any completed forms previously requested; or (3) after the review of an Applicant’s physical examination. The results of the physical examination and the information contained in the specific evaluation forms covered by this Supporting Statement 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 assignment and complete a tour of service without unreasonable disruption due to health problems.

If, based on the Applicant’s responses on the Health History Form, additional information is required in order to make an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems, then one or more of the forms submitted under OMB Control No. 0420-0550 may be sent to the Applicant.

The Peace Corps Report of Dental Examination 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.

2. The information in this 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 assignment and complete a tour of service without unreasonable disruption due to health problems. If it is determined that the Applicant has a reasonable chance of performing the essential assignment functions and completing a tour of service, the forms will also be used to establish the level of medical and other support, if any, that may be required to reasonably accommodate the Applicant. The information in this form are used as a baseline assessment for the Peace Corps Medical Officers overseas who are responsible for the Volunteer’s medical care. Finally, the Peace Corps may use the information in the forms as a point of reference in the event that, after completion of the Applicant’s service as a Volunteer, he or she makes a worker’s compensation claim under the Federal Employee Compensation Act (FECA).

Applicants’ qualifications for service are reviewed in a division of Peace Corps separate from the division that performs the medical clearance review. Those who make a judgment about whether an Applicant has the skills to serve as a Volunteer do not have access to medical clearance information about the Applicant. Additionally, each Applicant receives an individualized assessment of his or her medical conditions. Peace Corps does not have a blanket rule excluding Applicants with particular conditions. Applicants who are medically disqualified receive an explanation why they were not medically cleared, and they have the opportunity to appeal the clearance decision to the Pre-Service Review Board. Medical clearance decisions are not permanent, and Applicants who are not medically cleared may reapply.

3. The Peace Corps upgraded the medical component of the electronic application process as part of a larger quality improvement project. In conjunction with this project, medical staff reviewed and revised the medical screening forms including the Health History Form, Report of Physical Examination, Report of Dental Examination, and the Individual Specific Medical Evaluation Forms. These changes reduced time required for an Applicant and their health care providers to manage and complete the medical forms, reducing the number of medical forms and clarifying content based on the lessons learned from customer and health care provider feedback. Applicants access the forms via a secure online portal. Applicants download the forms for their health care providers to complete. Completed forms are scanned and uploaded back into the Applicant’s secure Peace Corps online portal or they are faxed or mailed to the Peace Corps Office of Medical Services. Most Applicants submit the forms electronically and only those with no electronic access submit a paper version. The Applicant’s health care provider does not have access to the Applicant’s secure Peace Corps online portal, therefore the provider is unable to complete and sign the form electronically.

4. There is no similar information available to the Peace Corps. This form is the only agency forms that collect this particular information concerning an Applicant’s dental health. While there are other medical forms, none of them addresses these conditions, treatments or needs with this degree of specificity. It would not make sense to combine this form with any of the other medical forms, as the Office of Medical Services will send this form to all Applicants, but only this form needs to be reviewed by a dentist.

5. This collection does not impact small business or other small entities.

6. All Applicants who complete a Health History Form will receive the form described above to better assess whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems and, if so, what accommodation may be needed. If the Peace Corps lacked the medical information obtained during the medical screening process, the Peace Corps would be unable to conduct the assessment.

7. There are no special circumstances. Collection will be conducted consistent with 5 C.F.R. 1320.6 guidelines.

8. The agency’s 60- Day notice was published in the Federal Register on June 20, 2024, 89 FR 51913. No public comments were received during the 60-day period. The 30- Day notice was published on August 23, 2024, 89 FR 68215.

9. No payment or gift is provided to Applicants applying for Peace Corps service. However, under 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.” In accordance with the authority provided in 22 U.S.C. 2504(e), the Peace Corps reimburses Applicants for some of the expenses that they incur for medical examinations that they undergo in connection with the Peace Corps Volunteer application process. This reimbursement is subject to overall limits and may not cover all costs incurred by the Applicant in connection with the medical evaluation. As there are different requirements for medical evaluations based on gender and age, the reimbursement limits vary based on those factors, which is displayed in the table

Coverage		Female Under 50	Female Over 50	Male Under 50	Male Over 50
Medical	Physical exam, lab work, any other requested tests	$165	$290	$125	$175
	Medical reimbursement rates based on required tests for your age and sex
Dental	Exam, X-rays (treatment not included)	$60	$60	$60	$60
Vision (If applicable)	Exam	$12	$12	$12	$12
Total		$387	$512	$347	$397
Vaccinations
Peace Corps Volunteers	Invitees to countries which require a Yellow Fever vaccination are eligible for 100% reimbursement. No other vaccinations are reimbursed.
Peace Corps Response Volunteer	Peace Corps Response Volunteers will receive reimbursement instructions

below.

In addition, Applicants are reimbursed only to the extent that they are not otherwise reimbursed by their insurance companies. Peace Corps is seeking Paperwork Reduction Act approval for this form.

10. Applicants are informed that the medical information they provide will be maintained in accordance with the Privacy Act. 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). The collection and storage of this information also complies with the Health Insurance Portability and Accountability Act (HIPAA). The Peace Corps’ internal rules ensure the confidential protection of medical information consistent with the Privacy Act and HIPAA. Applicants are informed of their rights under HIPAA before completing the forms.

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 hour burden: Based on the number of Volunteers projected to receive invitations to serve in the next year, it is estimated that 7000 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 5250 hours of dentist time (7000 Applicants x 45 minutes) and 10500 hours of Applicant time (7000 Applicants x 90 minutes).

13. Estimated Burden to the Public: The fee scale for the applicant population is FP-07-01 ($49,165) The wage rate for an FP-07-01 is calculated to be an hourly rate of $23.64 ($49,165/2080). The justification for using this rate is that most Applicants are recent college graduates just entering the work force; additionally, Peace Corps often hires Returned Volunteers after they complete their service, and they are hired at an FP-07-01 rate.

The calculation for estimating the burden to the public is (applicant time x applicant hourly wage) + (dentist time x dentist hourly wage). The dentist hourly wage was determined by consulting the Bureau of Labor Statistics’ May 2019 Occupational Employment and Wage Estimates for Healthcare Practioners and Occupational Technicians.

14. Estimated annual cost to the Federal Government: There is no start-up cost associated with this form. The estimated costs below reflect the additional time needed to review the information in this form over and above the time needed to review other medical information collected from the Applicant in the Health History Form and the Report of Physical Examination

For those Applicants who become Volunteers, the information in this form will also be used by Peace Corps Medical Officers overseas in providing medical care during the Volunteer’s service. The costs associated with the receipt and review of this information is indeterminate based on the wide range of Peace Corps Medical Officer hourly rates and the time associated with review of the medical reports in individual cases. It is understood that this is part of an everyday job requirement for all the Peace Corps Medical Officers in the field and reviewing this form in no way increases the costs to the Federal Government. If Peace Corps Medical Officer did not have the information in this form, they would have to acquire the information through some other means, which would add to their daily workload.

The dental exam form is reviewed by a dentist. Peace Corps dentists are on the FP-1 Pay scale with a mid-range rate of $74 an hour, which is $94 an hour with benefit costs included.

It is estimated that 7,000 Applicants will required to complete this form and return it to the Peace Corps. This form is reviewed by a dentist. It is estimated that it will take a dentist 8 minutes to review the Report of Dental Examination. The estimated cost for dentist review is $87,733.30 (7,000 Applicants x 8 minutes x $94/hr.).

15. There are no program changes or adjustments reported on the burden.

16. This information will not be quantified or published.

17. The Agency is not seeking approval to conceal or omit the expiration date for OMB approval of the information collection.

18. The agency is able to certify compliance with all provisions under Item 19 of OMB Form 83-I.

Section B. Collection of Information Employing Statistical Methods

This collection of information does not employ statistical methods.

1 The Peace Corps Act states that, except as provided in the Peace Corps Act, Volunteers are not employees for any purpose. 22 U.S.C. § 2504(a). Nevertheless, Volunteers are entitled to receive compensation under the Federal Employees Compensation Act for injuries received during service. 5 U.S.C. § 8142.