View Information Collection Request (ICR) Package
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View Information Collection (IC) List
View Supporting Statement and Other Documents
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:
201610-0420-005
Status:
Historical Inactive
Previous ICR Reference No:
201401-0420-004
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:
Yes
Type of Review Request:
Regular
OIRA Conclusion Action:
Improperly submitted and continue
Conclusion Date:
12/09/2016
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/02/2016
Terms of Clearance:
Multiple versions of the instrument are uploaded. Please amend the IC list to only indicate the instrument planned for electronic and paper filing .
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/2017
36 Months From Approved
03/31/2017
Responses
10,000
0
10,000
Time Burden (Hours)
7,500
0
7,500
Cost Burden (Dollars)
0
0
0
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:
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
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Health History Form
0420-0510
Health History Form
Health History Form (PC 1789)
PC-1789, PC-1789
Health History Form
,
Health History Form (paper version)
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:
The burden on this ICR is increased because of program change due to agency discretion.
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:
Yes
Description/Changes for Common Form Usage:
Approved RCFs using this ICR
Agency/Sub Agency
RCF ID
RCF Title
RCF Status
IC Title
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:
11/02/2016
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