OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Individual Specific Medical Evaluation Forms (15)

ICR 201808-0420-004 · OMB 0420-0550 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form PC-262-14 Mental Health Current Evaluation and Treatment Summary Form Form and Instruction Modified Available
Form PC-262-16 Required Peace Corps Immunization Documentation Form Form and Instruction Unchanged Available
Form PC-262-6 Substance-Related and Addictive Disorders Current Evaluation Form Form and Instruction Unchanged Available
Form PC-262-15 Functional Abilities Evaluation Form Form and Instruction Unchanged Repair queued
Form PC-262-13 Transfer of Care – Request for Information Form Form and Instruction Unchanged Available
Form PC-OMS-116 Prescription for Eyeglassess Form and Instruction Unchanged Available
Form PC-262-10 Insulin Dependent Diabetic Supplement Documentation Form Form and Instruction Unchanged Available
Form PC-262-12 Reactive Tuberculin Test Evaluation Form Form and Instruction Unchanged Available
Form PC-262-7 ECG/EKG Form Form and Instruction Unchanged Available
Form PC-262-9 Colon Cancer Screening Form Form and Instruction Unchanged Available
Form PC-262-11 Cervical Cancer Screening Form Form and Instruction Unchanged Available
Form PC-355-2 Mammogram Form Form and Instruction Unchanged Available
Form PC-262-8 Eating Disorder Treatment Summary Form Form and Instruction Unchanged Available
Form PC-262-3 Diabetes Diagnosis Form Form and Instruction Unchanged Available
Form PC-262-2 Asthma Evaluation Form Form and Instruction Unchanged Available
Justification for revised Mental Health form.docx Justification for No Material/Nonsubstantive Change Uploaded 2018-10-10 Available
0420-0550 Supporting Statement.docx Supporting Statement A Uploaded 2017-02-07 Available
PC-17.pdf Supplementary Document Uploaded 2012-07-12 Available
IC Document Collections
IC IDCollectionTypeStatusForm
224328 Mental Health Current Evaluation and Treatment Summary Form Form and Instruction Modified
224327 Required Peace Corps Immunization Documentation Form Form and Instruction Unchanged
224326 Substance-Related and Addictive Disorders Current Evaluation Form Form and Instruction Unchanged
224325 Functional Abilities Evaluation Form Form and Instruction Unchanged
224319 Transfer of Care – Request for Information Form Form and Instruction Unchanged
201724 Prescription for Eyeglassess Form and Instruction Unchanged
201719 Insulin Dependent Diabetic Supplement Documentation Form Form and Instruction Unchanged
201718 Reactive Tuberculin Test Evaluation Form Form and Instruction Unchanged
201717 ECG/EKG Form Form and Instruction Unchanged
201716 Colon Cancer Screening Form Form and Instruction Unchanged
201715 Cervical Cancer Screening Form Form and Instruction Unchanged
201714 Mammogram Form Form and Instruction Unchanged
201708 Eating Disorder Treatment Summary Form Form and Instruction Unchanged
201684 Diabetes Diagnosis Form Form and Instruction Unchanged
201683 Asthma Evaluation Form Form and Instruction Unchanged
ICR Details
0420-0550 201808-0420-004
Historical Active 201611-0420-001
PEACE
Individual Specific Medical Evaluation Forms (15)
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 11/02/2018
Retrieve Notice of Action (NOA) 10/10/2018
  Inventory as of this Action Requested Previously Approved
03/31/2020 03/31/2020 03/31/2020
18,498 0 18,498
19,037 0 19,037
0 0 0
The 16 forms listed may be sent to an individual Applicant at one of the following times in the medical review process: (1) after the Applicant completes the Health History Form and receives a nomination; (2) after a Peace Corps nurse reviews the Applicant's Health History Form and any completed forms previously requested; or (3) at the time of the Applicant's physical examination. The results of the physical examination and the information contained in the specific evaluation forms will be used to make an individualized determination as to whether an Applicant for Volunteer service will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems.
US Code: 22 USC 2504 Name of Law: Peace Corps Act
  
None
Not associated with rulemaking
  81 FR 81179 11/17/2016
82 FR 9402 02/06/2017
No
  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 18,498 18,498 0 0 0 0
Annual Time Burden (Hours) 19,037 19,037 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The burden changed due to program changes at the agency discretion.
$440,661
No
    Yes
    Yes
No
No
No
Uncollected
Virginia Burke 202 692-1887 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/10/2018