View Information Collection Request (ICR) Package

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: 0420-0546	ICR Reference No: 201610-0420-004
Status: Historical Active	Previous ICR Reference No: 201410-0420-002
Agency/Subagency: PEACE	Agency Tracking No:
Title: Report of Dental Examinitaion
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/02/2017
	Date Received in OIRA: 01/31/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	02/28/2018
Responses	5,600	0	5,400
Time Burden (Hours)	12,600	0	4,050
Cost Burden (Dollars)	1,008,000	0	864,000

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	5,600	5,400	200
Annual Time Burden (Hours)	12,600	4,050	8,550
Annual Cost Burden (Dollars)	1,008,000	864,000	144,000

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

Burden Increase Due to: Changing Regulations

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

Burden Reduction Due to:

Short Statement: The burden increased due to Agency discretion.

Common Form ICR: Yes
Description/Changes for Common Form Usage: 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 have 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 being made in 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 Applicants access the Dental Examination form via a secure online portal. Applicants will download the form for their dentist to complete. The Dental Exam form must be personally completed and signed by the examining dentist. The completed form can be scanned and uploaded into the Applicant’s secure Peace Corps online portal, faxed, or mailed to the Peace Corps Office of Medical Services.

Approved RCFs using this ICR

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

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