Submission for OMB Review; Request for Comments, 18273-18277 [2012-7339]
Download as PDF
Federal Register / Vol. 77, No. 59 / Tuesday, March 27, 2012 / Notices
II. Availability of Inspection Reports
inspection reports prepared by the NRC
staff. For information on how to access
The following table provides the
ADAMS accession numbers for the
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Dated at Rockville, Maryland, this 9th day
of March 2012.
For the U.S. Nuclear Regulatory
Commission.
Brian W. Smith,
Chief, Uranium Enrichment Branch, Division
of Fuel Cycle Safety and Safeguards, Office
of Nuclear Material Safety and Safeguards.
[FR Doc. 2012–7310 Filed 3–26–12; 8:45 am]
BILLING CODE 7590–01–P
PEACE CORPS
Submission for OMB Review; Request
for Comments
30-Day notice and request for
comments.
ACTION:
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 30 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 (44 U.S.C. chapter 35).
DATES: Comments must be submitted on
or before April 26, 2012.
ADDRESSES: Interested persons are
invited to submit comments regarding
this proposal. Comments should refer to
the proposal by name/or OMB approval
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SUMMARY:
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ADAMS, see the ADDRESSES section of
this document.
Date
ADAMS
Accession No.
....................................................................................................
January 25, 2012 .......................................................................
December 8, 2011 .....................................................................
December 16, 2011 ...................................................................
October 28, 2011 .......................................................................
June 15, 2011 ............................................................................
April 29, 2011 .............................................................................
July 21, 2010 .............................................................................
March 31, 2010 ..........................................................................
March 26, 2010 ..........................................................................
December 17, 2009 ...................................................................
October 8, 2009 .........................................................................
September 30, 2009 ..................................................................
June 26, 2009 ............................................................................
March 26, 2009 ..........................................................................
March 20, 2009 ..........................................................................
December 19, 2008 ...................................................................
October 30, 2008 .......................................................................
July 10, 2008 .............................................................................
April 24, 2008 .............................................................................
March 7, 2008 ............................................................................
November 2, 2007 .....................................................................
August 16, 2007 .........................................................................
May 24, 2007 .............................................................................
January 19, 2007 .......................................................................
Pending
ML12025A286
ML11342A131
ML11353A102
ML11301A218
ML111660886
ML111190268
ML102020385
ML100900329
ML100850424
ML093511013
ML092820188
ML092730612
ML091770643
ML090850669
ML090790642
ML083540709
ML083040618
ML081930118
ML081160345
ML080670475
ML073060571
ML072280647
ML071440430
ML070190661
Inspection Report Nos.
70–3103/2012–002
70–3103/2011–013
70–3103/2011–009
70–3103/2011–007
70–3103/2011–004
70–3103/2011–008
70–3103/2011–002
70–3103/2010–012
70–3103/2010–007
70–3103/2010–005
70–3103/2009–004
70–3103/2009–006
70–3103/2009–003
70–3103/2009–002
70–3103/2009–001
70–3103/2008–006
70–3103/2008–004
70–3103/2008–003
70–3103/2008–002
70–3103/2008–001
70–3103/2007–004
70–3103/2007–003
70–3103/2007–002
70–3103/2007–001
70–3103/2006–001
18273
number and should be sent via email to:
oira_submission@omb.eop.gov or fax to:
202–395–3086. Attention: Desk Officer
for Peace Corps.
FOR FURTHER INFORMATION CONTACT:
Denora Miller, FOIA Officer, Peace
Corps, 1111 20th Street NW.,
Washington, DC 20526, (202) 692–1236,
or email at pcfr@peacecorps.gov. Copies
of available documents submitted to
OMB may be obtained from Denora
Miller at address listed above.
SUPPLEMENTARY INFORMATION: The Peace
Corps Act states that ‘‘[t]he President
may enroll in the Peace Corps for
service abroad qualified citizens and
nationals of the United States (referred
to in this Act as ‘‘volunteers’’). The
terms and conditions of the enrollment
* * * of volunteers shall be exclusively
those set forth in this Act and those
consistent therewith which the
President may prescribe * * *’’ 22
U.S.C. 2504(a). Eligibility requirements
for the Peace Corps have been
prescribed in 22 CFR part 305. Among
those eligibility requirements is one
relating to medical status. An Applicant
‘‘must, with reasonable accommodation,
have the physical and mental capacity
required of a Volunteer to perform the
essential functions of the Peace Corps
Volunteer assignment for which he or
she is otherwise eligible and be able to
complete an agreed upon tour of service,
ordinarily two years, without undue
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disruption due to health problems.’’ 22
CFR 305.2(c). All applicants for service
must undergo a physical examination
and a dental evaluation prior to
Volunteer service to determine if they
meet this medical status eligibility
requirement. In addition, under 22
U.S.C. 2504(e), the Peace Corps provides
medical care to Volunteers during their
service and the information collected
will also be used in connection with
medical care and treatment during
Peace Corps service for applicants who
become Volunteers. Finally, the
information collected may serve as a
point of reference for any potential
future Volunteer worker’s compensation
claims.
Volunteers serve in 67 developing
countries where western-style
healthcare is often not available.
Volunteers are placed in remote
locations where they may suffer
hardship because they have no access to
running water and/or electricity. They
also may be placed in locations with
extreme environmental conditions
related to cold, heat or high altitude and
they may be exposed to diseases not
generally found in the U.S. Volunteers
may be placed many hours from the
Peace Corps medical office and not have
easy access to any health care provider.
Therefore, a thorough review of an
Applicant’s past medical history is an
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essential first step to determine their
suitability for service in Peace Corps.
The current process requires almost
all Applicants to undergo a costly and
time consuming full medical evaluation.
Under the current process, it sometimes
happens that after an Applicant has
spent large amounts of time and money,
the Peace Corps finds that the Applicant
is not medically qualified to serve. In
2012, the Peace Corps will change the
current process in order to reduce the
time and expense of Applicants and to
ensure that only those who accept an
invitation to serve undergo a complete
medical evaluation. However,
Applicants who have certain
particularly difficult to accommodate
conditions will be evaluated early in the
process. This will reduce the time and
expense for those Applicants who
would, even with reasonable
accommodation, not be likely to 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.
Under the new system, the Applicant
will begin the medical part of the
application process by completing a
comprehensive health history form
called the ‘‘Health History Form’’. After
completion of the Health History Form
and after passing preliminary nonhealth-related assessments, the
Applicant will be ‘‘nominated’’ to a
program. This nomination does not
guarantee an invitation to serve, but it
does hold a place so the Applicant may
proceed with the process. After a review
by the Peace Corps pre-service medical
staff of the Health History Form and any
supplemental forms that the Applicant
is required to submit following
nomination, the Applicant may be
medically pre-cleared. An Applicant
who is medically pre-cleared and who
accepts an invitation to serve as a Peace
Corps Volunteer undergoes a final
medical clearance. Final medical
clearance is on the basis of a complete
physical examination, as documented in
a Report of Physical Examination.
The forms listed below 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 covered by this Supporting
Statement will be used to make an
individualized determination as to
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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.
If, based on the Applicant’s responses
on the Health History Form, additional
information is required in order to make
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 undue
disruption due to health problems, then
one or more of the forms listed below
may be sent to the Applicant.
Method: The Peace Corps will
introduce these forms electronically as
part of a larger business process
improvement project. Applicants will
gain access to the forms via a secure
online portal. As described below, in
most instances, Applicants will have to
download the forms for their health care
providers to complete. Completed forms
can be scanned and uploaded back into
the Applicant’s secure Peace Corps
online portal or they can be faxed or
mailed to the Peace Corps Office of
Medical Services. The Peace Corps
anticipates that most Applicants will
submit the forms electronically and that
only those with no electronic access
will submit a paper version.
Title: Individual Specific Medical
Evaluation Forms (16).
OMB Control Number: 0420-pending.
Type of Review: New.
Respondents: Individuals/Physicians.
Respondents’ obligation to reply:
Required for Volunteer service.
Burden to the public:
• Allergy Treatment Form
(a) Estimated number of Applicants/
physicians: 100/100.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 20 minutes/10 minutes.
(d) Estimated total reporting burden:
33.3 hours/16.7 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection:
When an Applicant reports that he or
she is currently receiving allergy shot
treatments, Peace Corps provides the
Applicant with an Allergy Treatment
Form for his or her treating physician to
complete. The Peace Corps is not able
to arrange for Volunteers to receive
allergy shots during their Peace Corps
service. Peace Corps Volunteers
generally serve in areas that are isolated
and have limited access to Westerntrained providers and health care
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systems. The Applicant completes the
form after discussing with his or her
physician whether the Applicant will be
able to live overseas for 27 months of
Peace Corps service without receiving
allergy shots. The Applicant is required
to certify that the Applicant has
discussed stopping allergy shots with
his or her physician and that the
physician agrees that the allergy shots
can be stopped without unreasonable
risk of substantial harm to the
Applicant’s health.
• Asthma Evaluation Form
(a) Estimated number of Applicants/
physicians: 500/500.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 75 minutes/30 minutes.
(d) Estimated total reporting burden:
625 hours/250 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection:
When an Applicant reports on the
Health History Form symptoms of
moderate persistent or severe persistent
asthma in the past two years, he or she
will be provided an Asthma Evaluation
Form for the treating physician to
complete. The determination of whether
the reported symptoms indicate
moderate persistent or severe persistent
asthma is based on recognized
classifications of asthma severity. 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, as well as to certify that the
Applicant can safely serve 27 months
overseas. 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 undue 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.
• Diabetes Diagnosis Form
(a) Estimated number of Applicants/
physicians: 36/36.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 75 minutes/30 minutes.
(d) Estimated total reporting burden:
45 hours/18 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
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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, as well as
to certify that the Applicant can safely
serve 27 months overseas. 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 undue
disruption due to health problems. This
form will also be used to determine the
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.
• Disease Diagnosis Form
(a) Estimated number of Applicants/
physicians: 400/400.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 75 minutes/30 minutes.
(d) Estimated total reporting burden:
500 hours/200 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 a Disease
Diagnosis Form for the treating
physician to complete. The Disease
Diagnosis 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 Disease Diagnosis Form
asks the physician to document the
diagnosis, etiology, possible
complications and treatment, as well as
to certify that the Applicant can safely
serve 27 months overseas. 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 undue
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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 to take account of the
Applicant’s medical condition (e.g.,
avoidance of high altitudes or proximity
to a hospital).
• Low Body Mass Index Evaluation
Form
(a) Estimated number of Applicants/
physicians: 50/50.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 105 minutes/60 minutes.
(d) Estimated total reporting burden:
87.5 hours/50 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection:
When an Applicant reports a height and
weight on the Health History Form
consistent with a body mass index
(BMI) that is below 17 for women and
18 for men, the Applicant will be
provided a Low Body Mass Index
Evaluation Form for a physician to
complete. The Low Body Mass Index
Evaluation Form asks the physician to
indicate whether the Applicant’s low
BMI is indicative of any condition
which could be exacerbated during
Peace Corps service. 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 undue disruption due to health
problems. Based on the information on
the completed form, the Peace Corps
may determine that further medical
assessments are required.
• Mental Health Treatment Summary
Form
(a) Estimated number of Applicants/
physicians: 150/150.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 105 minutes/60 minutes.
(d) Estimated total reporting burden:
262.5 hours/150 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection: The
Mental Health Treatment 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 Treatment
Summary Form for a licensed mental
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18275
health counselor, psychiatrist or
psychologist to complete. The Mental
Health 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 undue
disruption. 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 undue 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.
• Eating Disorder Treatment Summary
Form
(a) Estimated number of Applicants/
physicians: 232/232.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 105 minutes/60 minutes.
(d) Estimated total reporting burden:
406 hours/232 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection: The
Eating Disorder Treatment Summary
Form 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 undue
disruption due to the diagnosis. This
form will be used as the basis for an
individualized determination as to
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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 undue
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.
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• Mental Health Current Evaluation
Form
(a) Estimated number of Applicants/
professional: 439/439.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 265 minutes/180 minutes.
(d) Estimated total reporting burden:
1,939 hours/1,317 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection: The
Mental Health Current Evaluation Form
is used when an Applicant reports a
mental health condition in the Health
History Form and it is determined that
a current mental health evaluation is
needed. A current mental health
evaluation might be needed if
information on the condition is outdated or previous reports on the
condition do not provide enough
information to adequately assess the
current status of the condition. In these
cases, the Applicant will be provided a
Mental Health Current Evaluation Form
for a licensed mental health counselor,
psychiatrist or psychologist to complete
over one to three evaluation sessions.
The Mental Health Current Evaluation
Form asks the mental health
professional to document the clinical
diagnoses, presenting symptoms, risk of
recurrence in a stressful overseas
environment, coping strategies,
evaluation of overall functioning,
psychotropic medications, current
psychological tests administered,
recommendations for follow up, and
any concerns that would prevent the
Applicant from completing 27 months
of service without undue 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 undue 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.
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• Alcohol/Substance Abuse Evaluation
Form
(a) Estimated number of Applicants/
specialist: 100/100.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 165 minutes/60 minutes.
(d) Estimated total reporting burden:
275 hours/100 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 Alcohol/Substance Abuse Current
Evaluation Form for a substance abuse
specialist to complete. The Alcohol/
Substance Abuse 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 27 months
of service without undue 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 undue 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.
• Mammogram Form
(a) Estimated number of Applicants:
224.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 105 minutes.
(d) Estimated total reporting burden:
392 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
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General description of collection: The
Mammogram Form is used with all
female Applicants who will be 50 years
of age or older, who have received
invitations to serve as Volunteers. The
purpose of the form is to provide the
Peace Corps with results of the
Applicant’s latest mammogram and to
record the wishes of the Applicant
regarding routine mammogram
screening during service. The Peace
Corps uses the information in the
Mammogram Form to determine if the
Applicant currently has breast cancer
and to ascertain whether the Applicant
wishes to receive routine mammogram
screening while in service. A female
Applicant who wishes to receive routine
mammogram screening during service
will be limited to being placed in a
country with mammogram screening
capabilities. If the Applicant waives
routine mammogram screening during
service, the Applicant’s physician also
completes this form in order to confirm
that the physician has reviewed the
Applicant’s risk factor assessment and
discussed the results with the Applicant
and concurs that foregoing screening
mammography represents an acceptable
risk.
• Pap Screening Form
(a) Estimated number of Applicants/
physicians: 2,695/2,695.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 25 minutes/15 minutes.
(d) Estimated total reporting burden:
1,123 hours/674 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection: The
Pap Screening Form is used with all
female Applicants who have received
invitations to serve as Volunteers. They
are required to obtain a Pap examination
within four months prior to their
departure. This form assists the Peace
Corps in determining whether a female
Applicant with mildly abnormal Pap
results will need to be placed in a
country with appropriate Pap follow-up
capabilities.
• Colon Cancer Screening Form
(a) Estimated number of Applicants:
354.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 60 minutes—165 minutes.
(d) Estimated total reporting burden:
354 hours–973.5 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 who have received
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invitations to serve as Volunteers. The
purpose of the form is 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.
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• ECG Form
(a) Estimated number of Applicants/
physicians: 354/354.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 25 minutes/15 minutes.
(d) Estimated total reporting burden:
147.5 hours/88.5 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection: The
ECG Form is used with all Applicants
who are 50 years of age or older, who
have received invitations to serve as
Volunteers. The purpose of the form is
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.
• Reactive Tuberculin Test Evaluation
Form
(a) Estimated number of Applicants/
physicians: 352/352.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 75–105 minutes/30 minutes.
(d) Estimated total reporting burden:
440–616 hours/176 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection: The
Reactive Tuberculin Test Evaluation
Form is used when an Applicant, who
has received an invitation to serve as
Volunteer, reports a history of reactivity
to tuberculosis skin testing or a history
of BCG vaccination in the Health
History Form or if a reactivity is
discovered as part of the Applicant’s
physical examination. 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,
VerDate Mar<15>2010
17:14 Mar 26, 2012
Jkt 226001
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 is
also required, along with treatment for
latent TB.
• Insulin Dependent Supplemental
Documentation Form
(a) Estimated number of Applicants/
physicians: 8/8.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 70 minutes/60 minutes.
(d) Estimated total reporting burden:
9.3 hours/8 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection: The
Insulin Dependent Supplemental
Documentation Form is used with
Applicants, who have received
invitations to serve as Volunteers, and
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.
• Prescription for Eyeglasses Form
(a) Estimated number of Applicants/
physicians: 2,432/2,432.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 105 minutes/15 minutes.
(d) Estimated total reporting burden:
4,256 hours/608 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General description of collection: The
Prescription for Eyeglasses Form is used
with Applicants, who have received
invitations to serve as Volunteers, and
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
PO 00000
Frm 00076
Fmt 4703
Sfmt 4703
18277
special instructions. This form is used
in order to enable the Peace Corps to
obtain replacement eyeglasses for a
Volunteer during 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.
Dated: This notice is issued in Washington,
DC on March 22, 2012.
Garry W. Stanberry,
Acting Associate Director, Management.
[FR Doc. 2012–7339 Filed 3–26–12; 8:45 am]
BILLING CODE 6051–01–P
SECURITIES AND EXCHANGE
COMMISSION
[Investment Company Act Release No.
29984; 812–13971]
Domini Social Investment Trust and
Domini Social Investments LLC; Notice
of Application
March 21, 2012.
Securities and Exchange
Commission (‘‘Commission’’).
ACTION: Notice of an application under
section 6(c) of the Investment Company
Act of 1940 (‘‘Act’’) for an exemption
from section 15(a) of the Act and rule
18f–2 under the Act, as well as from
certain disclosure requirements.
AGENCY:
Applicants
request an order that would permit them
to enter into and materially amend
subadvisory agreements without
shareholder approval and would grant
relief from certain disclosure
requirements.
APPLICANTS: Domini Social Investment
Trust (the ‘‘Trust’’) and Domini Social
Investments LLC (the ‘‘Adviser’’)
(collectively, ‘‘Applicants’’).
DATES: Filing Dates: The application was
filed October 26, 2011, and amended on
March 15, 2012.
HEARING OR NOTIFICATION OF HEARING: An
order granting the application will be
issued unless the Commission orders a
hearing. Interested persons may request
a hearing by writing to the
SUMMARY OF APPLICATION:
E:\FR\FM\27MRN1.SGM
27MRN1
Agencies
[Federal Register Volume 77, Number 59 (Tuesday, March 27, 2012)]
[Notices]
[Pages 18273-18277]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-7339]
=======================================================================
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PEACE CORPS
Submission for OMB Review; Request for Comments
ACTION: 30-Day notice and request for comments.
-----------------------------------------------------------------------
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 30 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 (44 U.S.C. chapter 35).
DATES: Comments must be submitted on or before April 26, 2012.
ADDRESSES: Interested persons are invited to submit comments regarding
this proposal. Comments should refer to the proposal by name/or OMB
approval number and should be sent via email to: oira_submission@omb.eop.gov or fax to: 202-395-3086. Attention: Desk Officer
for Peace Corps.
FOR FURTHER INFORMATION CONTACT: Denora Miller, FOIA Officer, Peace
Corps, 1111 20th Street NW., Washington, DC 20526, (202) 692-1236, or
email at pcfr@peacecorps.gov. Copies of available documents submitted
to OMB may be obtained from Denora Miller at address listed above.
SUPPLEMENTARY INFORMATION: The Peace Corps Act states that ``[t]he
President may enroll in the Peace Corps for service abroad qualified
citizens and nationals of the United States (referred to in this Act as
``volunteers''). The terms and conditions of the enrollment * * * of
volunteers shall be exclusively those set forth in this Act and those
consistent therewith which the President may prescribe * * *'' 22
U.S.C. 2504(a). Eligibility requirements for the Peace Corps have been
prescribed in 22 CFR part 305. Among those eligibility requirements is
one relating to medical status. An Applicant ``must, with reasonable
accommodation, have the physical and mental capacity required of a
Volunteer to perform the essential functions of the Peace Corps
Volunteer assignment for which he or she is otherwise eligible and be
able to complete an agreed upon tour of service, ordinarily two years,
without undue disruption due to health problems.'' 22 CFR 305.2(c). All
applicants for service must undergo a physical examination and a dental
evaluation prior to Volunteer service to determine if they meet this
medical status eligibility requirement. In addition, under 22 U.S.C.
2504(e), the Peace Corps provides medical care to Volunteers during
their service and the information collected will also be used in
connection with medical care and treatment during Peace Corps service
for applicants who become Volunteers. Finally, the information
collected may serve as a point of reference for any potential future
Volunteer worker's compensation claims.
Volunteers serve in 67 developing countries where western-style
healthcare is often not available. Volunteers are placed in remote
locations where they may suffer hardship because they have no access to
running water and/or electricity. They also may be placed in locations
with extreme environmental conditions related to cold, heat or high
altitude and they may be exposed to diseases not generally found in the
U.S. Volunteers may be placed many hours from the Peace Corps medical
office and not have easy access to any health care provider. Therefore,
a thorough review of an Applicant's past medical history is an
[[Page 18274]]
essential first step to determine their suitability for service in
Peace Corps.
The current process requires almost all Applicants to undergo a
costly and time consuming full medical evaluation. Under the current
process, it sometimes happens that after an Applicant has spent large
amounts of time and money, the Peace Corps finds that the Applicant is
not medically qualified to serve. In 2012, the Peace Corps will change
the current process in order to reduce the time and expense of
Applicants and to ensure that only those who accept an invitation to
serve undergo a complete medical evaluation. However, Applicants who
have certain particularly difficult to accommodate conditions will be
evaluated early in the process. This will reduce the time and expense
for those Applicants who would, even with reasonable accommodation, not
be likely to 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.
Under the new system, the Applicant will begin the medical part of
the application process by completing a comprehensive health history
form called the ``Health History Form''. After completion of the Health
History Form and after passing preliminary non-health-related
assessments, the Applicant will be ``nominated'' to a program. This
nomination does not guarantee an invitation to serve, but it does hold
a place so the Applicant may proceed with the process. After a review
by the Peace Corps pre-service medical staff of the Health History Form
and any supplemental forms that the Applicant is required to submit
following nomination, the Applicant may be medically pre-cleared. An
Applicant who is medically pre-cleared and who accepts an invitation to
serve as a Peace Corps Volunteer undergoes a final medical clearance.
Final medical clearance is on the basis of a complete physical
examination, as documented in a Report of Physical Examination.
The forms listed below 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 covered by this Supporting Statement 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.
If, based on the Applicant's responses on the Health History Form,
additional information is required in order to make 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 undue disruption
due to health problems, then one or more of the forms listed below may
be sent to the Applicant.
Method: The Peace Corps will introduce these forms electronically
as part of a larger business process improvement project. Applicants
will gain access to the forms via a secure online portal. As described
below, in most instances, Applicants will have to download the forms
for their health care providers to complete. Completed forms can be
scanned and uploaded back into the Applicant's secure Peace Corps
online portal or they can be faxed or mailed to the Peace Corps Office
of Medical Services. The Peace Corps anticipates that most Applicants
will submit the forms electronically and that only those with no
electronic access will submit a paper version.
Title: Individual Specific Medical Evaluation Forms (16).
OMB Control Number: 0420-pending.
Type of Review: New.
Respondents: Individuals/Physicians.
Respondents' obligation to reply: Required for Volunteer service.
Burden to the public:
Allergy Treatment Form
(a) Estimated number of Applicants/physicians: 100/100.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 20 minutes/10 minutes.
(d) Estimated total reporting burden: 33.3 hours/16.7 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: When an Applicant reports that
he or she is currently receiving allergy shot treatments, Peace Corps
provides the Applicant with an Allergy Treatment Form for his or her
treating physician to complete. The Peace Corps is not able to arrange
for Volunteers to receive allergy shots during their Peace Corps
service. Peace Corps Volunteers generally serve in areas that are
isolated and have limited access to Western-trained providers and
health care systems. The Applicant completes the form after discussing
with his or her physician whether the Applicant will be able to live
overseas for 27 months of Peace Corps service without receiving allergy
shots. The Applicant is required to certify that the Applicant has
discussed stopping allergy shots with his or her physician and that the
physician agrees that the allergy shots can be stopped without
unreasonable risk of substantial harm to the Applicant's health.
Asthma Evaluation Form
(a) Estimated number of Applicants/physicians: 500/500.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 75 minutes/30 minutes.
(d) Estimated total reporting burden: 625 hours/250 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: When an Applicant reports on the
Health History Form symptoms of moderate persistent or severe
persistent asthma in the past two years, he or she will be provided an
Asthma Evaluation Form for the treating physician to complete. The
determination of whether the reported symptoms indicate moderate
persistent or severe persistent asthma is based on recognized
classifications of asthma severity. 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, as well as to certify that the
Applicant can safely serve 27 months overseas. 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 undue 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.
Diabetes Diagnosis Form
(a) Estimated number of Applicants/physicians: 36/36.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 75 minutes/30 minutes.
(d) Estimated total reporting burden: 45 hours/18 hours.
(e) Estimated annual cost to respondents: Indeterminate.
[[Page 18275]]
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, as well as to certify that the Applicant can safely serve 27
months overseas. 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 undue
disruption due to health problems. This form will also be used to
determine the 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.
Disease Diagnosis Form
(a) Estimated number of Applicants/physicians: 400/400.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 75 minutes/30 minutes.
(d) Estimated total reporting burden: 500 hours/200 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 a Disease
Diagnosis Form for the treating physician to complete. The Disease
Diagnosis 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 Disease
Diagnosis Form asks the physician to document the diagnosis, etiology,
possible complications and treatment, as well as to certify that the
Applicant can safely serve 27 months overseas. 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 undue 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 to take account of the Applicant's
medical condition (e.g., avoidance of high altitudes or proximity to a
hospital).
Low Body Mass Index Evaluation Form
(a) Estimated number of Applicants/physicians: 50/50.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 105 minutes/60 minutes.
(d) Estimated total reporting burden: 87.5 hours/50 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: When an Applicant reports a
height and weight on the Health History Form consistent with a body
mass index (BMI) that is below 17 for women and 18 for men, the
Applicant will be provided a Low Body Mass Index Evaluation Form for a
physician to complete. The Low Body Mass Index Evaluation Form asks the
physician to indicate whether the Applicant's low BMI is indicative of
any condition which could be exacerbated during Peace Corps service.
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 undue disruption due to health
problems. Based on the information on the completed form, the Peace
Corps may determine that further medical assessments are required.
Mental Health Treatment Summary Form
(a) Estimated number of Applicants/physicians: 150/150.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 105 minutes/60 minutes.
(d) Estimated total reporting burden: 262.5 hours/150 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: The Mental Health Treatment 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 Treatment Summary Form for a licensed mental health counselor,
psychiatrist or psychologist to complete. The Mental Health 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 undue disruption. 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 undue 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.
Eating Disorder Treatment Summary Form
(a) Estimated number of Applicants/physicians: 232/232.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 105 minutes/60 minutes.
(d) Estimated total reporting burden: 406 hours/232 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: The Eating Disorder Treatment
Summary Form 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
undue disruption due to the diagnosis. This form will be used as the
basis for an individualized determination as to
[[Page 18276]]
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 undue 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.
Mental Health Current Evaluation Form
(a) Estimated number of Applicants/professional: 439/439.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 265 minutes/180 minutes.
(d) Estimated total reporting burden: 1,939 hours/1,317 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: The Mental Health Current
Evaluation Form is used when an Applicant reports a mental health
condition in the Health History Form and it is determined that a
current mental health evaluation is needed. A current mental health
evaluation might be needed if information on the condition is out-dated
or previous reports on the condition do not provide enough information
to adequately assess the current status of the condition. In these
cases, the Applicant will be provided a Mental Health Current
Evaluation Form for a licensed mental health counselor, psychiatrist or
psychologist to complete over one to three evaluation sessions. The
Mental Health Current Evaluation Form asks the mental health
professional to document the clinical diagnoses, presenting symptoms,
risk of recurrence in a stressful overseas environment, coping
strategies, evaluation of overall functioning, psychotropic
medications, current psychological tests administered, recommendations
for follow up, and any concerns that would prevent the Applicant from
completing 27 months of service without undue 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 undue 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.
Alcohol/Substance Abuse Evaluation Form
(a) Estimated number of Applicants/specialist: 100/100.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 165 minutes/60 minutes.
(d) Estimated total reporting burden: 275 hours/100 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 Alcohol/Substance Abuse Current Evaluation Form for a
substance abuse specialist to complete. The Alcohol/Substance Abuse
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 27 months of service without
undue 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 undue 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.
Mammogram Form
(a) Estimated number of Applicants: 224.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 105 minutes.
(d) Estimated total reporting burden: 392 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: The Mammogram Form is used with
all female Applicants who will be 50 years of age or older, who have
received invitations to serve as Volunteers. The purpose of the form is
to provide the Peace Corps with results of the Applicant's latest
mammogram and to record the wishes of the Applicant regarding routine
mammogram screening during service. The Peace Corps uses the
information in the Mammogram Form to determine if the Applicant
currently has breast cancer and to ascertain whether the Applicant
wishes to receive routine mammogram screening while in service. A
female Applicant who wishes to receive routine mammogram screening
during service will be limited to being placed in a country with
mammogram screening capabilities. If the Applicant waives routine
mammogram screening during service, the Applicant's physician also
completes this form in order to confirm that the physician has reviewed
the Applicant's risk factor assessment and discussed the results with
the Applicant and concurs that foregoing screening mammography
represents an acceptable risk.
Pap Screening Form
(a) Estimated number of Applicants/physicians: 2,695/2,695.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 25 minutes/15 minutes.
(d) Estimated total reporting burden: 1,123 hours/674 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: The Pap Screening Form is used
with all female Applicants who have received invitations to serve as
Volunteers. They are required to obtain a Pap examination within four
months prior to their departure. This form assists the Peace Corps in
determining whether a female Applicant with mildly abnormal Pap results
will need to be placed in a country with appropriate Pap follow-up
capabilities.
Colon Cancer Screening Form
(a) Estimated number of Applicants: 354.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 60 minutes--165 minutes.
(d) Estimated total reporting burden: 354 hours-973.5 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 who have
received
[[Page 18277]]
invitations to serve as Volunteers. The purpose of the form is 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.
ECG Form
(a) Estimated number of Applicants/physicians: 354/354.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 25 minutes/15 minutes.
(d) Estimated total reporting burden: 147.5 hours/88.5 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: The ECG Form is used with all
Applicants who are 50 years of age or older, who have received
invitations to serve as Volunteers. The purpose of the form is 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.
Reactive Tuberculin Test Evaluation Form
(a) Estimated number of Applicants/physicians: 352/352.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 75-105 minutes/30
minutes.
(d) Estimated total reporting burden: 440-616 hours/176 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: The Reactive Tuberculin Test
Evaluation Form is used when an Applicant, who has received an
invitation to serve as Volunteer, reports a history of reactivity to
tuberculosis skin testing or a history of BCG vaccination in the Health
History Form or if a reactivity is discovered as part of the
Applicant's physical examination. 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 is also required, along with treatment for latent TB.
Insulin Dependent Supplemental Documentation Form
(a) Estimated number of Applicants/physicians: 8/8.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 70 minutes/60 minutes.
(d) Estimated total reporting burden: 9.3 hours/8 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: The Insulin Dependent
Supplemental Documentation Form is used with Applicants, who have
received invitations to serve as Volunteers, and 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.
Prescription for Eyeglasses Form
(a) Estimated number of Applicants/physicians: 2,432/2,432.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 105 minutes/15 minutes.
(d) Estimated total reporting burden: 4,256 hours/608 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General description of collection: The Prescription for Eyeglasses
Form is used with Applicants, who have received invitations to serve as
Volunteers, and 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.
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.
Dated: This notice is issued in Washington, DC on March 22,
2012.
Garry W. Stanberry,
Acting Associate Director, Management.
[FR Doc. 2012-7339 Filed 3-26-12; 8:45 am]
BILLING CODE 6051-01-P