View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0420-0510
ICR Reference No:
201201-0420-002
Status:
Historical Active
Previous ICR Reference No:
201103-0420-001
Agency/Subagency:
PEACE
Agency Tracking No:
Title:
Peace Corps Health History Form
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
07/13/2012
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/30/2012
Terms of Clearance:
Peace Corps will continue to work on streamlining the process for applications and identify improvements made during the next renewal request. Peace Corps will also explore the possibility of combining ICR No. 201201-0420-001, "Report of Physical Examination" and ICR No. 201203-0420-001 "Individual Specific Medical Evaluation Forms (16)" into this collection.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2014
36 Months From Approved
08/31/2014
Responses
10,000
0
14,700
Time Burden (Hours)
7,500
0
11,025
Cost Burden (Dollars)
0
0
260,000
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 56821
09/14/2011
30-day Notice:
Federal Register Citation:
Citation Date:
77 FR 4375
01/27/2012
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Health History Form (PC 1789)
PC-1789, PC-1789
Health History Form
,
Health History Form (paper version)
Health Status Review
PC-1789
Health Status Review
Report of Medical Examination
PC-1790S
Report of Medical Examination
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
10,000
14,700
0
-14,700
10,000
0
Annual Time Burden (Hours)
7,500
11,025
0
-11,025
7,500
0
Annual Cost Burden (Dollars)
0
260,000
0
-260,000
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:
Using Information Technology
Short Statement:
The current process requires all Applicants to complete in its entirety a Health Status Review form (Peace Corps Form PC-1789). Under the new system, the Applicant will begin the medical part of the application process by completing the Health History Form covered by this Supporting Statement, a form which is much more comprehensive in scope than OMB form 0420-0510. The Health History Form will replace Health Status Review Form and is expected to significantly reduce the need for medical office visits and tests. The Health History Form will be completed online in an interactive process in which only questions relevant to each Applicant's medical history (based on responses to previous questions) are presented
Annual Cost to Federal Government:
$301,250
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
Agency Contact:
Denora Miller 202 692-1236 dmiller4@peacecorps.gov
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:
01/30/2012
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