Notice2024-07582
Information Collection Request; Submission for OMB Review
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
April 10, 2024
Issuing agencies
Peace Corps
Abstract
The Peace Corps will be submitting the following information collection request to the Office of Management and Budget (OMB) for review and approval. The purpose of this notice is to allow 60 days for public comment in the Federal Register preceding submission to OMB. We are conducting this process in accordance with the Paperwork Reduction Act of 1995.
Full Text
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<title>Federal Register, Volume 89 Issue 70 (Wednesday, April 10, 2024)</title>
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[Federal Register Volume 89, Number 70 (Wednesday, April 10, 2024)]
[Notices]
[Pages 25286-25289]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2024-07582]
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PEACE CORPS
Information Collection Request; Submission for OMB Review
AGENCY: Peace Corps.
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ACTION: 60-Day notice and request for comments.
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SUMMARY: The Peace Corps will be submitting the following information
collection request to the Office of Management and Budget (OMB) for
review and approval. The purpose of this notice is to allow 60 days for
public comment in the Federal Register preceding submission to OMB. We
are conducting this process in accordance with the Paperwork Reduction
Act of 1995.
DATES: Submit comments on or before June 10, 2024.
ADDRESSES: Comments should be addressed to James Olin, FOIA/Privacy Act
Officer. James Olin can be contacted by phone 202-692-2507 or email at
<a href="/cdn-cgi/l/email-protection#b6c6d5d0c4f6c6d3d7d5d3d5d9c4c6c598d1d9c0"><span class="__cf_email__" data-cfemail="4e3e2d283c0e3e2b2f2d2b2d213c3e3d60292138">[email protected]</span></a>. Email comments must be made in text and not in
attachments.
FOR FURTHER INFORMATION CONTACT: James Olin, Peace Corps, at
<a href="/cdn-cgi/l/email-protection#4d3d2e2b3f0d3d282c2e282e223f3d3e632a223b"><span class="__cf_email__" data-cfemail="a4d4c7c2d6e4d4c1c5c7c1c7cbd6d4d78ac3cbd2">[email protected]</span></a> or by telephone at (202) 692-2507.
SUPPLEMENTARY INFORMATION:
Title: Individual Specific Medical Evaluation Forms (15).
OMB Control Number: 0420-0550.
Type of Request: Revision/New.
Affected Public: Individuals/Physicians.
Respondents Obligation to Reply: Voluntary.
Respondents: Potential and current volunteers
Burden to the Public:
<bullet> Asthma Evaluation Form.
(a) Estimated number of Applicants/physicians: 700/700
(b) Frequency of response: one time
(c) Estimated average burden per response: 75 minutes/30 minutes
(d) Estimated total reporting burden: 875 hours/350 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: When an Applicant reports on the
Health History Form any history of asthma, he or she will be provided
an Asthma Evaluation Form for the treating physician to complete. The
Asthma Evaluation Form asks for the physician to document the
Applicant's condition of asthma, including any asthma symptoms,
triggers, treatments, or limitations or restrictions due to the
condition. This form will be used as the basis for an individualized
determination as to whether the Applicant will, with reasonable
accommodation, be able to perform the essential functions of a Peace
Corps Volunteer and complete a tour of service without unreasonable
disruption due to health problems. This form will also be used to
determine the type of accommodation that may be needed, such as
placement of the Applicant within reasonable proximity to a hospital in
case treatment is needed for a severe asthma attack.
<bullet> Diabetes Diagnosis Form.
(a) Estimated number of Applicants/physicians: 55/55
(b) Frequency of response: one time
(c) Estimated average burden per response: 75 minutes/30 minutes
(d) Estimated total reporting burden: 69 hours/28 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: When an Applicant reports the
condition of diabetes Type 1 on the Health History Form, the Applicant
will be provided a Diabetes Diagnosis Form for the treating physician
to complete. In certain cases, the Applicant may also be asked to have
the treating physician complete a Diabetes Diagnosis Form if the
Applicant reports the condition of diabetes Type 2 on the Health
History Form. The Diabetes Diagnosis Form asks the physician to
document the diabetes diagnosis, etiology, possible complications, and
treatment. This form will be used as the basis for an individualized
determination as to whether the Applicant will, with reasonable
accommodation, be able to perform the essential functions of a Peace
Corps Volunteer assignment and complete a tour of service without
unreasonable disruption due to health problems. This form will also be
used to determine the type of accommodation that may be needed, such as
placement of an Applicant who requires the use of insulin in order to
ensure that adequate insulin storage facilities are available at the
Applicant's site.
<bullet> Transfer of Care--Request for Information Form.
(a) Estimated number of Applicants/physicians: 1,270/1,270
(b) Frequency of response: one time
(c) Estimated average burden per response: 75 minutes/30 minutes
(d) Estimated total reporting burden: 1,588 hours/635 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: When an Applicant reports on the
Health History Form a medical condition of significant severity (other
than one covered by another form), he or she may be provided the
Transfer of Care--Request for Information Form for the treating
physician to complete. The Transfer of Care--Request for Information
Form may also be provided to an Applicant whose responses on the Health
History Form indicate that the Applicant may have an unstable medical
condition that requires ongoing treatment. The Transfer of Care--
Request for Information Form asks the physician to document the
diagnosis, current treatment, physical limitations and the likelihood
of significant progression of the condition over the next three years.
This form will be used as the basis for an individualized determination
as to whether the Applicant will, with reasonable accommodation, be
able to perform the essential functions of a Peace Corps Volunteer
assignment and complete a tour of service without unreasonable
disruption due to health problems. This form will also be used to
determine the type of accommodation (e.g., avoidance of high altitudes
or proximity to a hospital)that may be needed to manage the Applicant's
medical condition.
<bullet> Mental Health Current Evaluation and Treatment Summary
Form.
(a) Estimated number of Applicants/professional: 1,221/1,221
(b) Frequency of response: one time
(c) Estimated average burden per response: 105 minutes/60 minutes
(d) Estimated total reporting burden: 2,137 hours/1,221 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The Mental Health Current
Evaluation Form will be used when an Applicant reports on the Health
History Form a history of certain serious mental health conditions,
such as bipolar disorder, schizophrenia, mental health hospitalization,
attempted suicide or cutting, or treatments or medications related to
these conditions. In these cases, an Applicant will be provided a
Mental Health Current Evaluation and Treatment Summary Form for a
licensed mental health counselor, psychiatrist or psychologist to
complete. The Mental Health Current Evaluation and Treatment Summary
Form asks the counselor, psychiatrist or psychologist to document the
dates and frequency of therapy sessions, clinical diagnoses, symptoms,
course of treatment, psychotropic medications, mental health history,
level of functioning, prognosis, risk of exacerbation or recurrence
while overseas, recommendations for follow up and any concerns that
would prevent the Applicant from completing 27 months of service
without unreasonable disruption. A current mental health evaluation
might be needed if information on the condition is out-
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dated or previous reports on the condition do not provide enough
information to adequately assess the current status of the
condition.This form will be used as the basis for an individualized
determination as to whether the Applicant will, with reasonable
accommodation, be able to perform the essential functions of a Peace
Corps Volunteer and complete a tour of service without unreasonable
disruption due to health problems. This form will also be used to
determine the type of accommodation that may be needed, such as
placement of the Applicant in a country with appropriate mental health
support.
<bullet> Functional Abilities Evaluation Form.
(a) Estimated number of Applicants/professional: 300/300
(b) Frequency of response: one time
(c) Estimated average burden per response: 90 minutes/45 minutes
(d) Estimated total reporting burden: 390 hours/225 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: When an Applicant reports on the
Health History Form a functional ability limitation he or she will be
provided this form to determine the type of accommodation and/or
placement program support (e.g., proximity to program site, support
support devices) that may be needed to manage the Applicant's medical
condition.. This form will be used as the basis for an individualized
determination as to whether the Applicant will, with reasonable
accommodation, be able to perform the essential functions of a Peace
Corps Volunteer assignment and complete a tour of service without
unreasonable disruption due to health problems.
<bullet> Eating Disorder Treatment Summary Form.
(a) Estimated number of Applicants/physicians: 282/282
(b) Frequency of response: one time
(c) Estimated average burden per response: 105 minutes/60 minutes
(d) Estimated total reporting burden: 494 hours/282 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The Eating Disorder Treatment
Summary will be used when an Applicant reports a past or current eating
disorder diagnosis in the Health History Form. In these cases the
Applicant is provided an Eating Disorder Treatment Summary Form for a
mental health specialist, preferably with eating disorder training, to
complete. The Eating Disorder Treatment Summary Form asks the mental
health specialist to document the dates and frequency of therapy
sessions, clinical diagnoses, presenting problems and precipitating
factors, symptoms, Applicant's weight over the past three years,
relevant family history, course of treatment, psychotropic medications,
mental health history inclusive of eating disorder behaviors, level of
functioning, prognosis, risk of recurrence in a stressful overseas
environment, recommendations for follow up, and any concerns that would
prevent the Applicant from completing 27 months of service without
unreasonable disruption due to the diagnosis. This form will be used as
the basis for an individualized determination as to whether the
Applicant will, with reasonable accommodation, be able to perform the
essential functions of a Peace Corps Volunteer assignment and complete
a tour of service without unreasonable disruption due to health
problems. This form will also be used to determine the type of
accommodation that may be needed, such as placement of the Applicant in
a country with appropriate mental health support.
<bullet> Substance-Related and Addictive Disorders Current
Evaluation Form.
(a) Estimated number of Applicants/specialist: 373/373
(b) Frequency of response: one time
(c) Estimated average burden per response: 165 minutes/60 minutes
(d) Estimated total reporting burden: 1,026 hours/373 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The Alcohol/Substance Abuse
Current Evaluation Form is used when an Applicant reports in the Health
History Form a history of substance abuse (i.e., alcohol or drug
related problems such as blackouts, daily or heavy drinking patterns or
the misuse of illegal or prescription drugs) and that this substance
abuse affects the Applicant's daily living or that the Applicant has
ongoing symptoms of substance abuse. In these cases, the Applicant is
provided an Substance-Related and Addictive Disorders Current
Evaluation Form for a substance abuse specialist to complete. The
Substance-Related and Addictive Disorders Current Evaluation Form asks
the substance abuse specialist to document the history of alcohol/
substance abuse, dates and frequency of any therapy sessions, which
alcohol/substance abuse assessment tools were administered, mental
health diagnoses, psychotropic medications, self harm behavior, current
clinical assessment of alcohol/substance use, clinical observations,
risk of recurrence in a stressful overseas environment, recommendations
for follow up, and any concerns that would prevent the Applicant from
completing a tour of service without unreasonable disruption due to the
diagnosis. This form will be used as the basis for an individualized
determination as to whether the Applicant will, with reasonable
accommodation, be able to perform the essential functions of a Peace
Corps Volunteer and complete a tour of service without unreasonable
disruption due to health problems. This form will also be used to
determine the type of accommodation that may be needed, such as
placement of the Applicant in a country with appropriate sobriety
support or counseling support.
<bullet> Mammogram Waiver Form.
(a) Estimated number of Applicants: 148
(b) Frequency of response: one time
(c) Estimated average burden per response: 105 minutes
(d) Estimated total reporting burden: 259 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The Mammogram Form is used for
all Applicants who have female breasts and will be 50 years of age or
older during service who wish to waive routine mammogram screening
during service. If an Applicant waives routine mammogram screening
during service, the Applicant's physician is asked to complete this
form in order to make a general assessment of the Applicant's
statistical breast cancer risk and discussed the results with the
Applicant including the potential adverse health consequence of
foregoing screening mammography.
<bullet> Cervical Cancer Screening Form.
(a) Estimated number of Applicants: 3,600/3,600
(b) Frequency of response: one time
(c) Estimated average burden per response: 40 minutes/30 minutes
(d) Estimated total reporting burden: 2,400 hours/1,800 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The Cervical Cancer Screening
Form is used with all Applicants with a cervix. Prior to medical
clearance, female Applicants are required to submit a current cervical
cancer screening examination and Pap cytology report based the American
Society for Colploscopy and Cervical Pathology (ASCCP) screening time-
line for their age and Pap history. This form assists the Peace Corps
in determining whether an Applicant with mildly
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abnormal Pap history will need to be placed in a country with
appropriate support.
<bullet> Colon Cancer Screening Form.
(a) Estimated number of Applicants: 575
(b) Frequency of response: one time
(c) Estimated average burden per response: 60 minutes-165 minutes
(d) Estimated total reporting burden: 575 hours-1,581 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The Colon Cancer Screening Form
is used with all Applicants who are 50 years of age or older to provide
the Peace Corps with the results of the Applicant's latest colon cancer
screening. Any testing deemed appropriate by the American Cancer
Society is accepted. The Peace Corps uses the information in the Colon
Cancer Screening Form to determine if the Applicant currently has colon
cancer. Additional instructions are included pertaining to abnormal
test results.
<bullet> ECG Form.
(a) Estimated number of Applicants/physicians: 575/575
(b) Frequency of response: one time
(c) Estimated average burden per response: 25 minutes/15 minutes
(d) Estimated total reporting burden: 240 hours/144 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The ECG/EKG Form is used with
all Applicants who are 50 years of age or older to provide the Peace
Corps with the results of an electrocardiogram. The Peace Corps uses
the information in the electrocardiogram to assess whether the
Applicant has any cardiac abnormalities that might affect the
Applicant's service. Additional instructions are included pertaining to
abnormal test results. The electrocardiogram is performed as part of
the Applicant's physical examination.
<bullet> Reactive Tuberculin Test Evaluation Form.
(a) Estimated number of Applicants/physicians: 392/392
(b) Frequency of response: one time
(c) Estimated average burden per response: 75-105 minutes/30 minutes
(d) Estimated total reporting burden: 490-686 hours/196 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The Reactive Tuberculin Test
Evaluation Form is used when an Applicant reports a history of
treatment for active tuberculosis or a history of a positive
tuberculosis (TB) test on their Health History Form or if a positive TB
test result is noted as a component of the Applicant's physical
examination findings. In these cases, the Applicant is provided a
Reactive Tuberculin Test Evaluation Form for the treating physician to
complete. The treating physician is asked to document the type and date
of a current TB test, TB test history, diagnostic tests if indicated,
treatment history, risk assessment for developing active TB, current TB
symptoms, and recommendations for further evaluation and treatment. In
the case of a positive result on the TB test, a chest x-ray may be
required, along with treatment for latent TB.
<bullet> Insulin Dependent Supplemental Documentation Form.
(a) Estimated number of Applicants/physicians: 14/14
(b) Frequency of response: one time
(c) Estimated average burden per response: 70 minutes/60 minutes
(d) Estimated total reporting burden: 16 hours/14 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The Insulin Dependent
Supplemental Documentation Form is used with Applicants who have
reported on the Health History Form that they have insulin dependent
diabetes. In these cases, the Applicant is provided an Insulin
Dependent Supplemental Documentation Form for the treating physician to
complete. The Insulin Dependent Supplemental Documentation Form asks
the treating physician to document that he or she has discussed with
the Applicant medication (insulin) management, including whether an
insulin pump is required, as well as the care and maintenance of all
required diabetes related monitors and equipment. This form assists the
Peace Corps in determining whether the Applicant will be in need of
insulin storage while in service and, if so, will assist the Peace
Corps in determining an appropriate placement for the Applicant.
<bullet> Prescription for Eyeglasses Form.
(a) Estimated number of Applicants/physicians: 3,293/3,293
(b) Frequency of response: one time
(c) Estimated average burden per response: 60 minutes/15 minutes
(d) Estimated total reporting burden: 3,293 hours/824 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The Prescription for Eyeglasses
is used with Applicants who have reported on the Health History Form
that they use corrective lenses or otherwise have uncorrected vision
that is worse than 20/40. In these cases, Applicants are provided a
Prescription for Eyeglasses Form for their prescriber to indicate
eyeglasses frame measurements, lens instructions, type of lens, gross
vision and any special instructions. This form is used in order to
enable the Peace Corps to obtain replacement eyeglasses for a Volunteer
during service.
<bullet> Required Peace Corps Immunizations Form.
(a) Estimated number of Applicants/physicians: 5,600
(b) Frequency of response: one time
(c) Estimated average burden per response: 60 minutes
(d) Estimated total reporting burden: 5,600 hours
(e) Estimated annual cost to respondents: Indeterminate
General Description of Collection: The Required Peace Corps
Immunizations Form is used to informed Applicants of the specific
vaccines and/or documented proof of immunity required for medical
clearance for the specific country of service. The form advises the
Applicant that all other Center for Disease Control (CDC) recommended
vaccinations will be administered after arrival in-country. This form
assists the Peace Corps with establishing a baseline of the Applicants
immunization history and prepare for any additional vaccines
recommended for country of service.
Request for Comment: Peace Corps invites comments on whether the
proposed collections of information are necessary for proper
performance of the functions of the Peace Corps, including whether the
information will have practical use; the accuracy of the agency's
estimate of the burden of the proposed collection of information,
including the validity of the information to be collected; and, ways to
minimize the burden of the collection of information on those who are
to respond, including through the use of automated collection
techniques, when appropriate, and other forms of information
technology.
This notice is issued in Washington, DC, on April 5, 2024.
James Olin,
FOIA/Privacy Act Officer.
[FR Doc. 2024-07582 Filed 4-9-24; 8:45 am]
BILLING CODE 6051-01-P
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