Information Collection Request, Submission for OMB Review, 7713-7717 [2014-02719]
Download as PDF
<![CDATA[
Federal Register / Vol. 79, No. 27 / Monday, February 10, 2014 / Notices
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 (covered under OMB
control number 0420–0510), the
Applicant may be medically precleared. 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 (PC–1790S).
The information contained in the
Report of Physical Examination 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 and,
if so, to establish the level of medical
and other support, if any, that may be
required to reasonably accommodate the
Applicant.
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 February 3, 2014.
Denora Miller,
FOIA/Privacy Act Officer, Management.
[FR Doc. 2014–02726 Filed 2–7–14; 8:45 am]
BILLING CODE 6051–01–P
mstockstill on DSK4VPTVN1PROD with NOTICES
PEACE CORPS
Information Collection Request,
Submission for OMB Review
Peace Corps.
30-Day notice and request for
comments.
AGENCY:
ACTION:
The Peace Corps will be
submitting the following information
collection requests to the Office of
SUMMARY:
VerDate Mar<15>2010
19:25 Feb 07, 2014
Jkt 232001
Management and Budget (OMB) for
Extension without change of a currently
approved information collection. In
compliance with the Paperwork
Reduction Act of 1995 (44 U.S.C.
Chapter 35), the Peace Corps invites the
general public to comment on the
extension, without change, of currently
approved information collection,
Individual Specific Medical Evaluation
Forms (16) (OMB 0420–0550). This
process is conducted in accordance with
5 CFR 1320.10. Peace Corps received no
comments during the 60-day notice.
DATES: Comments regarding this
collection must be received on or before
March 12, 2014.
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/Privacy Act
Officer, Peace Corps, 1111 20th Street
NW., Washington, DC 20526, (202) 692–
1236, or email at pcfr@
mailto:ddunevant@
peacecorps.govpeacecorps.gov.
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
PO 00000
Frm 00084
Fmt 4703
Sfmt 4703
7713
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 Westerntrained 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
E:\FR\FM\10FEN1.SGM
10FEN1
7714
Federal Register / Vol. 79, No. 27 / Monday, February 10, 2014 / Notices
mstockstill on DSK4VPTVN1PROD with NOTICES
(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
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
VerDate Mar<15>2010
19:25 Feb 07, 2014
Jkt 232001
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
PO 00000
Frm 00085
Fmt 4703
Sfmt 4703
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
E:\FR\FM\10FEN1.SGM
10FEN1
Federal Register / Vol. 79, No. 27 / Monday, February 10, 2014 / Notices
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.
mstockstill on DSK4VPTVN1PROD with NOTICES
• 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,
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
VerDate Mar<15>2010
19:25 Feb 07, 2014
Jkt 232001
(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
PO 00000
Frm 00086
Fmt 4703
Sfmt 4703
7715
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
E:\FR\FM\10FEN1.SGM
10FEN1
7716
Federal Register / Vol. 79, No. 27 / Monday, February 10, 2014 / Notices
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
mstockstill on DSK4VPTVN1PROD with NOTICES
(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
VerDate Mar<15>2010
19:25 Feb 07, 2014
Jkt 232001
(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
PO 00000
Frm 00087
Fmt 4703
Sfmt 4703
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.
E:\FR\FM\10FEN1.SGM
10FEN1
Federal Register / Vol. 79, No. 27 / Monday, February 10, 2014 / Notices
This notice is issued in Washington, DC,
on February 3, 2014.
Denora Miller,
FOIA/Privacy Act Officer, Management.
[FR Doc. 2014–02719 Filed 2–7–14; 8:45 am]
BILLING CODE 6051–01–P
PEACE CORPS
Information Collection Request;
Submission for OMB Review
Peace Corps.
30-day notice and request for
comments.
AGENCY:
ACTION:
The Peace Corps will be
submitting the following information
collection requests to the Office of
Management and Budget (OMB) for
Extension without change of a currently
approved information collection. In
compliance with the Paperwork
Reduction Act of 1995 (44 U.S.C.
Chapter 35), the Peace Corps invites the
general public to comment on the
extension, without change, of currently
approved information collection, Peace
Corps Volunter Health History Form
(OMB 0420–0510). This process is
conducted in accordance with 5 CFR
1320.10. Peace Corps received no
comments during the 60-day notice.
DATES: Comments regarding this
collection must be received on or before
March 12, 2014.
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/Privacy Act
Officer, Peace Corps, 1111 20th Street
NW., Washington, DC 20526, (202) 692–
1236, or email at pcfr@
mailto:ddunevant@
peacecorps.govpeacecorps.gov.
SUPPLEMENTARY INFORMATION:
Method: The Health History Form will
be completed online in an interactive
process in which only questions
relevant to each Applicant’s medical
history (based on responses to previous
questions) are presented.
Title: Peace Corps Volunter Health
History form (PC 1789).
OMB Control Number: 0420–0510.
Type of Request: Extension without
change of a currently approved
collection.
Affected Public: Individuals or
households
Respondents Obligation To Reply:
Voluntary
mstockstill on DSK4VPTVN1PROD with NOTICES
SUMMARY:
VerDate Mar<15>2010
19:25 Feb 07, 2014
Jkt 232001
Burden to the Public:
a. Estimated number of respondents.
b. Estimated average burden per response.
c. Frequency of response ....
d. Annual reporting burden ..
e. Estimated annual cost to
respondents.
10,000
45 minutes
one time
7,500 hours
Indeterminate
General Description of Collection: The
Peace Corps Act requires that
Volunteers receive health examinations
prior to their service. The information
collected is required for consideration
for Peace Corps Volunteer service. The
Health History Form is used to
document the medical history of each
individual Applicant. It is a self-report
of pre-existing medical conditions and
is used to help determine 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.
Request For Comment: Peace Corps
invites comments on whether the
proposed collection of information is
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 issued in Washington, DC on
February 3, 2014.
Denora Miller,
FOIA/Privacy Act Officer, Management.
[FR Doc. 2014–02723 Filed 2–7–14; 8:45 am]
RAILROAD RETIREMENT BOARD
Agency Forms Submitted for OMB
Review, Request for Comments
Summary: In accordance with the
Paperwork Reduction Act of 1995 (44
U.S.C. Chapter 35), the Railroad
Retirement Board (RRB) is forwarding 3
Information Collection Requests (ICR) to
the Office of Information and Regulatory
Affairs (OIRA), Office of Management
and Budget (OMB). Our ICR describes
the information we seek to collect from
the public. Review and approval by
Frm 00088
Fmt 4703
OIRA ensures that we impose
appropriate paperwork burdens.
The RRB invites comments on the
proposed collections of information to
determine (1) the practical utility of the
collections; (2) the accuracy of the
estimated burden of the collections; (3)
ways to enhance the quality, utility, and
clarity of the information that is the
subject of collection; and (4) ways to
minimize the burden of collections on
respondents, including the use of
automated collection techniques or
other forms of information technology.
Comments to the RRB or OIRA must
contain the OMB control number of the
ICR. For proper consideration of your
comments, it is best if the RRB and
OIRA receive them within 30 days of
the publication date.
1. Title and purpose of information
collection: Certification Regarding
Rights to Unemployment Benefits; OMB
3220–0079.
Under Section 4 of the Railroad
Unemployment Insurance Act (RUIA),
an employee who leaves work
voluntarily is disqualified for
unemployment benefits unless the
employee left work for good cause and
is not qualified for unemployment
benefits under any other law. RRB Form
UI–45, Claimant’s Statement—
Voluntary Leaving of Work, is used by
the RRB to obtain the claimant’s
statement when the claimant, the
claimant’s employer, or another source
indicates that the claimant has
voluntarily left work.
Completion of Form UI–45 is required
to obtain or retain benefits. One
response is received from each
respondent.
Previous Requests for Comments: The
RRB has already published the initial
60-day notice (78 FR 70358 on
November 25, 2013) required by 44
U.S.C. 3506(c)(2). That request elicited
no comments.
Information Collection Request (ICR)
BILLING CODE 6051–01–P
PO 00000
7717
Sfmt 4703
Title: Certification Regarding Rights to
Unemployment Benefits.
OMB Control Number: 3220–0079.
Form(s) submitted: UI–45.
Type of request: Extension without
change of a currently approved
collection.
Affected public: Individuals or
Households.
Abstract: In administering the
disqualification for the voluntary
leaving of work provision of Section 4
of the Railroad Unemployment
Insurance Act, the Railroad Retirement
Board investigates an unemployment
claim that indicates the claimant left
voluntarily. The certification obtains
E:\FR\FM\10FEN1.SGM
10FEN1
]]>Agencies
[Federal Register Volume 79, Number 27 (Monday, February 10, 2014)]
[Notices]
[Pages 7713-7717]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-02719]
-----------------------------------------------------------------------
PEACE CORPS
Information Collection Request, Submission for OMB Review
AGENCY: Peace Corps.
ACTION: 30-Day notice and request for comments.
-----------------------------------------------------------------------
SUMMARY: The Peace Corps will be submitting the following information
collection requests to the Office of Management and Budget (OMB) for
Extension without change of a currently approved information
collection. In compliance with the Paperwork Reduction Act of 1995 (44
U.S.C. Chapter 35), the Peace Corps invites the general public to
comment on the extension, without change, of currently approved
information collection, Individual Specific Medical Evaluation Forms
(16) (OMB 0420-0550). This process is conducted in accordance with 5
CFR 1320.10. Peace Corps received no comments during the 60-day notice.
DATES: Comments regarding this collection must be received on or before
March 12, 2014.
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/Privacy Act
Officer, Peace Corps, 1111 20th Street NW., Washington, DC 20526, (202)
692-1236, or email at
pcfr@mailto:ddunevant@peacecorps.govpeacecorps.gov.
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
[[Page 7714]]
(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 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
[[Page 7715]]
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, 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
[[Page 7716]]
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 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.
[[Page 7717]]
This notice is issued in Washington, DC, on February 3, 2014.
Denora Miller,
FOIA/Privacy Act Officer, Management.
[FR Doc. 2014-02719 Filed 2-7-14; 8:45 am]
BILLING CODE 6051-01-P
