Information Collection Request; Submission for OMB Review, 72125-72128 [2013-28729]

Agencies

• PEACE CORPS

[Federal Register Volume 78, Number 231 (Monday, December 2, 2013)]
[Notices]
[Pages 72125-72128]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2013-28729]


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PEACE CORPS


Information Collection Request; Submission for OMB Review

AGENCY: Peace Corps.

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 (44 U.S.C. Chapter 35).

DATES: Comments must be submitted on or before January 31, 2014.

ADDRESSES: Comments should be addressed to Denora Miller, FOIA/Privacy 
Act Officer, Peace Corps, 1111 20th Street NW., Washington, DC 20526. 
Denora Miller can be contacted by telephone at 202-692-1236 or email at 
pcfr@peacecorps.gov. Email comments must be made in text and not in 
attachments.

FOR FURTHER INFORMATION CONTACT: Denora Miller at Peace Corps address 
above.

SUPPLEMENTARY INFORMATION: Volunteers serve in 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 essential first step to determine their 
suitability for service in Peace Corps.
    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 information contained in 
the specific medical 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 meet the 
essential eligibility requirements for a Peace Corps Volunteer and 
complete a tour of service without undue disruption due to health 
problems.
    Method: Applicants gain access to the forms via a secure online 
portal. 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.
    Title: Individual Specific Medical Evaluation Forms (16).
    OMB Control Number: 0420-0550.
    Type of Request: Extension without change of a currently approved 
collection.
    Affected Public: Individuals/Physicians.
    Respondents' Obligation to Reply: Voluntary.

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 is 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 is used as the 
basis for an individualized determination as to whether the Applicant 
will, with reasonable accommodation, be able to meet the essential 
eligibility requirements for a Peace Corps Volunteer and complete a 
tour of service without undue disruption due to health problems. This 
form is also used to determine the type of accommodation that may be 
needed, such as placement

[[Page 72126]]

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.
    General Description of Collection: When an Applicant reports the 
condition of diabetes Type 1 on the Health History Form, the Applicant 
is 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 is used as the basis for an individualized determination as to 
whether the Applicant will, with reasonable accommodation, be able to 
meet the essential eligibility requirements for a Peace Corps Volunteer 
and complete a tour of service without undue disruption due to health 
problems. This form is also 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.
 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 is used as the 
basis for an individualized determination as to whether the Applicant 
will, with reasonable accommodation, be able to meet the essential 
eligibility requirements for a Peace Corps Volunteer and complete a 
tour of service without undue disruption due to health problems. This 
form is also 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 is used as the basis for an individualized determination as 
to whether the Applicant will, with reasonable accommodation, be able 
to meet the essential eligibility requirements for 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 
is 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 is 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 is used as the basis for an individualized 
determination as to whether the Applicant will, with reasonable 
accommodation, be able to meet the essential eligibility requirements 
for a Peace Corps Volunteer and complete a tour of service without 
undue disruption due to health problems. This form is also 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 is 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,

[[Page 72127]]

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 is used as the basis for an 
individualized determination as to whether the Applicant will, with 
reasonable accommodation, be able to meet the essential eligibility 
requirements for a Peace Corps Volunteer and complete a tour of service 
without undue disruption due to health problems. This form is also 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 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 is used as the basis for an individualized 
determination as to whether the Applicant will, with reasonable 
accommodation, be able to meet the essential eligibility requirements 
for a Peace Corps Volunteer and complete a tour of service without 
undue disruption due to health problems. This form is also 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 is used as the basis 
for an individualized determination as to whether the Applicant will, 
with reasonable accommodation, be able to meet the essential 
eligibility requirements for a Peace Corps Volunteer and complete a 
tour of service without undue disruption due to health problems. This 
form is also 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.

[[Page 72128]]

 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 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.

    This notice is issued in Washington, DC, on November 21, 2013.
Denora Miller,
FOIA/Privacy Act Officer, Management.
[FR Doc. 2013-28729 Filed 11-29-13; 8:45 am]
BILLING CODE 6051-01-P