Individual Specific Medical Evaluation Forms (15)

Forms and Documents

Document Name	Status
Form PC-262-14 Mental Health Current Evaluation and Treatment Summary Form Form and Instruction	New
Form PC-262-16 Required Peace Corps Immunization Documentation Form Form and Instruction	New
Form PC-262-6 Substance-Related and Addictive Disorders Current Evaluation Form Form and Instruction	New
Form PC-262-15 Functional Abilities Evaluation Form Form and Instruction	New
Form PC-262-13 Transfer of Care – Request for Information Form Form and Instruction	New
Form PC-OMS-116 Prescription for Eyeglassess Form and Instruction	Modified
Form PC-262-10 Insulin Dependent Diabetic Supplement Documentation Form Form and Instruction	Modified
Form PC-262-12 Reactive Tuberculin Test Evaluation Form Form and Instruction	Modified
Form PC-262-7 ECG/EKG Form Form and Instruction	Modified
Form PC-262-9 Colon Cancer Screening Form Form and Instruction	Modified
Form PC-262-11 Cervical Cancer Screening Form Form and Instruction	Modified
Form PC-355-2 Mammogram Form Form and Instruction	Modified
Form PC-262-6 Alcohol/Substance Abuse Current Evaluation Form and Instruction	Removed
Form TG-510-2 Mental Health Current Evaluation Form and Instruction	Removed
Form PC-262-8 Eating Disorder Treatment Summary Form Form and Instruction	Modified
Form TG-510-3 Mental Health Treatment Summary Form Form and Instruction	Removed
Form PC-262-4 Low Body Mass Index Evaluation Form Form and Instruction	Removed
Form PC-262-5 Disease Diagnosis Form Form and Instruction	Removed
Form PC-262-3 Diabetes Diagnosis Form Form and Instruction	Modified
Form PC-262-2 Asthma Evaluation Form Form and Instruction	Modified
Form PC-262-1 Allergy Treatment Form Form and Instruction	Removed
0420-0550 Supporting Statement.docx Supporting Statement A	2017-02-07
PC-17.pdf Supplementary Document	2012-07-12

IC Document Collections

IC ID	Document Title	Status
224328	Mental Health Current Evaluation and Treatment Summary Form Form and Instruction	New
224327	Required Peace Corps Immunization Documentation Form Form and Instruction	New
224326	Substance-Related and Addictive Disorders Current Evaluation Form Form and Instruction	New
224325	Functional Abilities Evaluation Form Form and Instruction	New
224319	Transfer of Care – Request for Information Form Form and Instruction	New
201724	Prescription for Eyeglassess Form and Instruction	Modified
201719	Insulin Dependent Diabetic Supplement Documentation Form Form and Instruction	Modified
201718	Reactive Tuberculin Test Evaluation Form Form and Instruction	Modified
201717	ECG/EKG Form Form and Instruction	Modified
201716	Colon Cancer Screening Form Form and Instruction	Modified
201715	Cervical Cancer Screening Form Form and Instruction	Modified
201714	Mammogram Form Form and Instruction	Modified
201710	Alcohol/Substance Abuse Current Evaluation Form and Instruction	Removed
201709	Mental Health Current Evaluation Form and Instruction	Removed
201708	Eating Disorder Treatment Summary Form Form and Instruction	Modified
201707	Mental Health Treatment Summary Form Form and Instruction	Removed
201686	Low Body Mass Index Evaluation Form Form and Instruction	Removed
201685	Disease Diagnosis Form Form and Instruction	Removed
201684	Diabetes Diagnosis Form Form and Instruction	Modified
201683	Asthma Evaluation Form Form and Instruction	Modified
201682	Allergy Treatment Form Form and Instruction	Removed

ICR Details

OMB Control No: 0420-0550	ICR Reference No: 201611-0420-001
Status: Historical Active	Previous ICR Reference No: 201401-0420-006
Agency/Subagency: PEACE	Agency Tracking No:
Title: Individual Specific Medical Evaluation Forms (15)
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: 03/06/2017
	Date Received in OIRA: 02/07/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	03/31/2017
Responses	18,498	0	16,528
Time Burden (Hours)	19,037	0	31,951
Cost Burden (Dollars)	0	0	0

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Abstract: The 16 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:
	81 FR 81179	11/17/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 9402	02/06/2017
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
Mental Health Treatment Summary Form	TG-510-3	Mental Health Treatment Summary
Functional Abilities Evaluation Form	PC-262-15	Functional Abilities Evaluation Form
Substance-Related and Addictive Disorders Current Evaluation Form	PC-262-6	Substance-Related and Addictive Disorders Current Evaluation Form
Reactive Tuberculin Test Evaluation Form	PC-262-12	Reactive Tuberculin Test Evaluation Form
Insulin Dependent Diabetic Supplement Documentation Form	PC-262-10	Insulin Dependent Diabetic Supplemental Documentation Form
Eating Disorder Treatment Summary Form	PC-262-8	Eating Disorder Treatment Summary Form
Colon Cancer Screening Form	PC-262-9	Colon Cancer Screening Form
Allergy Treatment Form	PC-262-1	Allergy Treatment Form
Low Body Mass Index Evaluation Form	PC-262-4	Low Body Mass Index Evaluation Form
Disease Diagnosis Form	PC-262-5	Disease Diagnosis Evaluation Form
Mental Health Current Evaluation	TG-510-2	Mental Health Current Evaluation Form
Transfer of Care – Request for Information Form	PC-262-13	Transfer of Care form
Required Peace Corps Immunization Documentation Form	PC-262-16	Required Peace Corps Immunization Documentation Form
Mental Health Current Evaluation and Treatment Summary Form	PC-262-14	Mental Health Current Evaluation and Treatment Summary Form
Cervical Cancer Screening Form	PC-262-11	Cervical Cancer Screening Form
ECG/EKG Form	PC-262-7	ECG/EKG Form
Prescription for Eyeglassess	PC-OMS-116	Prescription for Eyeglassess
Asthma Evaluation Form	PC-262-2	Asthma Evaluation Form
Diabetes Diagnosis Form	PC-262-3	Diabetes Evaluation Form
Alcohol/Substance Abuse Current Evaluation	PC-262-6	Alcohol/Substance Abuse Current Evaluation Form
Mammogram Form	PC-355-2	Mammogram Waiver Form

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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	18,498	16,528	0	1,970	0	0
Annual Time Burden (Hours)	19,037	31,951	0	-12,914	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden changed due to program changes at the agency discretion.

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Annual Cost to Federal Government: $440,661

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

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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: 02/07/2017

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