Peace Corps Volunter Medical Application and Health Status Review

Forms and Documents

Document Name	Status
Form PC-1789 Health Status Review Form and Instruction	Modified
Form PC-1790 Report of Dental Examination Form and Instruction	Removed
Form PC-1790S Report of Medical Examination Form and Instruction	Modified
22 USC 2504.pdf Supplementary Document	2011-06-21
Supporting Statement 0420-0510.pdf Supporting Statement A	2011-06-21

IC Document Collections

IC ID	Document Title	Status
917	Health Status Review Form and Instruction	Modified
185725	Report of Dental Examination Form and Instruction	Removed
183919	Report of Medical Examination Form and Instruction	Modified

ICR Details

OMB Control No: 0420-0510	ICR Reference No: 201103-0420-001
Status: Historical Active	Previous ICR Reference No: 200705-0420-010
Agency/Subagency: PEACE	Agency Tracking No:
Title: Peace Corps Volunter Medical Application and Health Status Review
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/21/2011
	Date Received in OIRA: 06/21/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	36 Months From Approved	08/31/2011
Responses	14,700	0	21,700
Time Burden (Hours)	11,025	0	13,275
Cost Burden (Dollars)	260,000	0	564,000

---

Abstract: All Peace Corps Volunteer applicants must undergo a physical examination prior to service during the application process to ensure good health and be able to serve without undue disruption due to health problems.

---

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

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 17164	03/28/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 33374	06/08/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Report of Dental Examination	PC-1790	Report of Dental Examination
Report of Medical Examination	PC-1790S	Report of Medical Examination
Health Status Review	PC-1789	Health Status Review

---

ICR Summary 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	14,700	21,700	0	-12,000	5,000	0
Annual Time Burden (Hours)	11,025	13,275	0	-9,525	7,275	0
Annual Cost Burden (Dollars)	260,000	564,000	0	-304,000	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Changing Forms

Short Statement: The burden decreased because the Dental Evaluation is now submitted separately as that form has had some changes. The Report of Medical Exam and the Health Status Review are the same as previously submitted. In addition, in the last three years the percentage of forms submitted electronically has increased.

---

Annual Cost to Federal Government: $265,034

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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? Uncollected

---

Common Form ICR:  No

---

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: 06/21/2011

---