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OMB Control No: 0420-0510	ICR Reference No: 202509-0420-001
Status: Received in OIRA	Previous ICR Reference No: 202407-0420-002
Agency/Subagency: PEACE	Agency Tracking No: PC-1789
Title: Peace Corps Health History Form
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: Yes
Type of Review Request: Regular	Date Submitted to OIRA: 09/30/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	23,000	0
Time Burden (Hours)	17,250	0
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Change Due to Potential Violation of the PRA
Annual Number of Responses	23,000	23,000
Annual Time Burden (Hours)	17,250	17,250
Annual Cost Burden (Dollars)	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: Cutting Redundancy

Short Statement: The Health History Form was updated to reflect the Executive Orders issued by the current Administration.

Annual Cost to Federal Government: $100,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

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? No

Agency Contact: Jay Olin 202 692-2507 jolin@peacecorps.gov