Peace Corps Health History Form

Forms and Documents

Document Name	Status
Form PC-1789 Health History Form (PC 1789) Form and Instruction	Modified
Justification for revised DME_Final 1_25_16.docx Supplementary Document	2017-02-10
DME Form - OMB changes.docx Supplementary Document	2017-02-10
PC-17.pdf Supplementary Document	2012-07-12
2017 HHF Supporting Statement.docx Supporting Statement A	2017-02-10
22 USC 2504.pdf Supplementary Document	2011-06-21

IC Document Collections

IC ID	Document Title	Status
200891	Health History Form (PC 1789) Form and Instruction	Modified

ICR Details

OMB Control No: 0420-0510	ICR Reference No: 201612-0420-002
Status: Historical Active	Previous ICR Reference No: 201401-0420-004
Agency/Subagency: PEACE	Agency Tracking No: PC-1789
Title: Peace Corps Health History Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/10/2017
	Date Received in OIRA: 12/20/2016
Terms of Clearance: Peace Corps must submit an amended request to OMB to implement an electronic version of this form.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	03/31/2017
Responses	23,000	0	10,000
Time Burden (Hours)	17,250	0	7,500
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): US Code: 22 USC 2504(e) 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 39291	06/16/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 63504	09/15/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Health History Form (PC 1789)	PC-1789	Health History 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	23,000	10,000	0	13,000	0	0
Annual Time Burden (Hours)	17,250	7,500	0	9,750	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: This revised Health History Form which replaces the current Health History Form will result in most Applicants answering significantly fewer questions than they would with the current Health History Form. Applicants will gain access to the Health History Form via a secure online portal. The link to the portal will be sent to applicants via email. The Peace Corps anticipates that most Applicants will complete the Health History Form online and that only those few with no electronic access (expected to be no more than 10 Applicants a year) will submit a paper version.

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Annual Cost to Federal Government: $100,000

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:  Yes

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

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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: 12/20/2016

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