Information Collection Request Submission for OMB Review, 81179-81182 [2016-27565]

Download as PDF 81179 asabaliauskas on DSK3SPTVN1PROD with NOTICES Federal Register / Vol. 81, No. 222 / Thursday, November 17, 2016 / Notices Time, Monday through Friday, excluding government holidays. Participants who believe that they have a good cause for not submitting documents electronically must file an exemption request, in accordance with 10 CFR 2.302(g), with their initial paper filing stating why there is good cause for not filing electronically and requesting authorization to continue to submit documents in paper format. Such filings must be submitted by: (1) First class mail addressed to the Office of the Secretary of the Commission, U.S. Nuclear Regulatory Commission, Washington, DC 20555–0001, Attention: Rulemaking and Adjudications Staff; or (2) courier, express mail, or expedited delivery service to the Office of the Secretary, 11555 Rockville Pike, Rockville, Maryland, 20852, Attention: Rulemaking and Adjudications Staff. Participants filing a document in this manner are responsible for serving the document on all other participants. Filing is considered complete by firstclass mail as of the time of deposit in the mail, or by courier, express mail, or expedited delivery service upon depositing the document with the provider of the service. A presiding officer, having granted an exemption request from using E-Filing, may require a participant or party to use E-Filing if the presiding officer subsequently determines that the reason for granting the exemption from use of E-Filing no longer exists. Documents submitted in adjudicatory proceedings will appear in the NRC’s electronic hearing docket which is available to the public at http:// ehd1.nrc.gov/ehd/, unless excluded pursuant to an order of the Commission, or the presiding officer. Participants are requested not to include personal privacy information, such as social security numbers, home addresses, or home phone numbers in their filings, unless an NRC regulation or other law requires submission of such information. However, in some instances, a petition will require including information on local residence in order to demonstrate a proximity assertion of interest in the proceeding. With respect to copyrighted works, except for limited excerpts that serve the purpose of the adjudicatory filings and would constitute a Fair Use application, participants are requested not to include copyrighted materials in their submission. The Commission will issue a notice or order granting or denying a hearing request or intervention petition, designating the issues for any hearing that will be held and designating the VerDate Sep<11>2014 21:24 Nov 16, 2016 Jkt 241001 Presiding Officer. A notice granting a hearing will be published in the Federal Register and served on the parties to the hearing. For further details with respect to this application, see the application dated July 22, 2016. Dated at Rockville, Maryland, this 8th day of November 2016. For the Nuclear Regulatory Commission. Balwant K. Singal, Senior Project Manager, Plant Licensing Branch IV–1, Division of Operating Reactor Licensing, Office of Nuclear Reactor Regulation. [FR Doc. 2016–27654 Filed 11–16–16; 8:45 am] BILLING CODE 7590–01–P PEACE CORPS Information Collection Request Submission for OMB Review Peace Corps. 60-day notice and request for comments. AGENCY: 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 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: Submit comments on or before January 17, 2017. ADDRESSES: Comments should be addressed to Denora Miller, FOIA/ Privacy Act Officer. 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. SUMMARY: SUPPLEMENTARY INFORMATION: Title: Individual Specific Medical Evaluation Forms (15). OMB Control Number: 0420–0550. Type of Request: Revision/New. Affected Public: Individuals/ Physicians. Respondents Obligation to Reply: Voluntary. Respondents: Potential and current volunteers. Burden to the Public: • Asthma Evaluation Form (a) Estimated number of Applicants/physicians. (b) Frequency of response ... PO 00000 Frm 00127 Fmt 4703 700/700. one time. Sfmt 4703 (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 75 minutes/30 minutes. 875 hours/350 hours. Indeterminate. General Description of Collection: When an Applicant reports on the Health History Form any history of asthma, he or she will be provided an Asthma Evaluation Form for the treating physician to complete The Asthma Evaluation Form asks for the physician to document the Applicant’s condition of asthma, including any asthma symptoms, triggers, treatments, or limitations or restrictions due to the condition. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation that may be needed, such as placement of the Applicant within reasonable proximity to a hospital in case treatment is needed for a severe asthma attack. • Diabetes Diagnosis Form (a) Estimated number of Applicants/physicians. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 55/55. one time. 75 minutes/30 minutes. 69 hours/28 hours. Indeterminate. General Description of Collection: When an Applicant reports the condition of diabetes Type 1 on the Health History Form, the Applicant will be provided a Diabetes Diagnosis Form for the treating physician to complete. In certain cases, the Applicant may also be asked to have the treating physician complete a Diabetes Diagnosis Form if the Applicant reports the condition of diabetes Type 2 on the Health History Form. The Diabetes Diagnosis Form asks the physician to document the diabetes diagnosis, etiology, possible complications, and treatment. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation that may be needed, such as placement E:\FR\FM\17NON1.SGM 17NON1 81180 Federal Register / Vol. 81, No. 222 / Thursday, November 17, 2016 / Notices 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. • Transfer of Care—Request for Information Form (a) Estimated number of Applicants/physicians. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 1270/1270. one time. 75 minutes/30 minutes. 1588 hours/635 hours. Indeterminate. General Description of Collection: When an Applicant reports on the Health History Form a medical condition of significant severity (other than one covered by another form), he or she may be provided the Transfer of Care—Request for Information Form for the treating physician to complete. The Transfer of Care—Request for Information Form may also be provided to an Applicant whose responses on the Health History Form indicate that the Applicant may have an unstable medical condition that requires ongoing treatment. The Transfer of Care— Request for Information Form asks the physician to document the diagnosis, current treatment, physical limitations and the likelihood of significant progression of the condition over the next three years. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation (e.g., avoidance of high altitudes or proximity to a hospital) that may be needed to manage the Applicant’s medical condition. • Mental Health Current Evaluation and Treatment Summary Form asabaliauskas on DSK3SPTVN1PROD with NOTICES (a) Estimated number of Applicants/professional. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 1221/1221. one time. 105 minutes/60 minutes. 2137 hours/1221 hours. Indeterminate. General Description of Collection: The Mental Health Current Evaluation Form will be used when an Applicant reports on the Health History Form a history of certain serious mental health conditions, such as bipolar disorder, schizophrenia, mental health hospitalization, attempted suicide or VerDate Sep<11>2014 21:24 Nov 16, 2016 Jkt 241001 cutting, or treatments or medications related to these conditions. In these cases, an Applicant will be provided a Mental Health Current Evaluation and Treatment Summary Form for a licensed mental health counselor, psychiatrist or psychologist to complete. The Mental Health Current Evaluation and Treatment Summary Form asks the counselor, psychiatrist or psychologist to document the dates and frequency of therapy sessions, clinical diagnoses, symptoms, course of treatment, psychotropic medications, mental health history, level of functioning, prognosis, risk of exacerbation or recurrence while overseas, recommendations for follow up and any concerns that would prevent the Applicant from completing 27 months of service without unreasonable disruption. A current mental health evaluation might be needed if information on the condition is outdated or previous reports on the condition do not provide enough information to adequately assess the current status of the condition. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation that may be needed, such as placement of the Applicant in a country with appropriate mental health support. • Functional Abilities Evaluation Form (a) Estimated number of Applicants/professional. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 300/300. one time. 90 minutes/45 minutes. 390 hours/225 hours. Indeterminate. General Description of Collection: When an Applicant reports on the Health History Form a functional ability limitation he or she will be provided this form to determine the type of accommodation and/or placement program support (e.g., proximity to program site, support support devices) that may be needed to manage the Applicant’s medical condition. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without PO 00000 Frm 00128 Fmt 4703 Sfmt 4703 unreasonable disruption due to health problems. • Eating Disorder Treatment Summary Form (a) Estimated number of Applicants/physicians. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 282/282. one time. 105 minutes/60 minutes. 494 hours/282 hours. Indeterminate. General Description of Collection: The Eating Disorder Treatment Summary will be used when an Applicant reports a past or current eating disorder diagnosis in the Health History Form. In these cases the Applicant is provided an Eating Disorder Treatment Summary Form for a mental health specialist, preferably with eating disorder training, to complete. The Eating Disorder Treatment Summary Form asks the mental health specialist to document the dates and frequency of therapy sessions, clinical diagnoses, presenting problems and precipitating factors, symptoms, Applicant’s weight over the past three years, relevant family history, course of treatment, psychotropic medications, mental health history inclusive of eating disorder behaviors, level of functioning, prognosis, risk of recurrence in a stressful overseas environment, recommendations for follow up, and any concerns that would prevent the Applicant from completing 27 months of service without unreasonable disruption due to the diagnosis. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer assignment and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation that may be needed, such as placement of the Applicant in a country with appropriate mental health support. • Substance-Related and Addictive Disorders Current Evaluation Form (a) Estimated number of Applicants/specialist. (b) Frequency of response ... (c) Estimated average burden per response165 minutes/60. (d) Estimated total reporting burden1026 hours/373 hours. (e) Estimated annual cost to respondents. 373/373. one time. minutes. . Indeterminate. General Description of Collection: The Alcohol/Substance Abuse Current E:\FR\FM\17NON1.SGM 17NON1 81181 Federal Register / Vol. 81, No. 222 / Thursday, November 17, 2016 / Notices Evaluation Form is used when an Applicant reports in the Health History Form a history of substance abuse (i.e., alcohol or drug related problems such as blackouts, daily or heavy drinking patterns or the misuse of illegal or prescription drugs) and that this substance abuse affects the Applicant’s daily living or that the Applicant has ongoing symptoms of substance abuse. In these cases, the Applicant is provided an Substance-Related and Addictive Disorders Current Evaluation Form for a substance abuse specialist to complete. The Substance-Related and Addictive Disorders Current Evaluation Form asks the substance abuse specialist to document the history of alcohol/ substance abuse, dates and frequency of any therapy sessions, which alcohol/ substance abuse assessment tools were administered, mental health diagnoses, psychotropic medications, self harm behavior, current clinical assessment of alcohol/substance use, clinical observations, risk of recurrence in a stressful overseas environment, recommendations for follow up, and any concerns that would prevent the Applicant from completing a tour of service without unreasonable disruption due to the diagnosis. This form will be used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without unreasonable disruption due to health problems. This form will also be used to determine the type of accommodation that may be needed, such as placement of the Applicant in a country with appropriate sobriety support or counseling support. • Mammogram Waiver Form asabaliauskas on DSK3SPTVN1PROD with NOTICES (a) Estimated number of Applicants. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 148. one time. 105 minutes. 259 hours. • Cervical Cancer Screening Form (a) Estimated number of Applicants. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 3600/3600. one time. 40 minutes/30 minutes. 2400 hours/1800 hours. Indeterminate. General Description of Collection: The Cervical Cancer Screening Form is used with all Applicants with a cervix. Prior to medical clearance, female Applicants are required to submit a current cervical cancer screening examination and Pap cytology report based the American Society for Colploscopy and Cervical Pathology (ASCCP) screening time-line for their age and Pap history. This form assists the Peace Corps in determining whether an Applicant with mildly abnormal Pap history will need to be placed in a country with appropriate support. • Colon Cancer Screening Form (a) Estimated number of Applicants. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 575. one time. 60 minutes—165 minutes. 575 hours—1581 hours. Indeterminate. General Description of Collection: The Colon Cancer Screening Form is used with all Applicants who are 50 years of age or older to provide the Peace Corps with the results of the Applicant’s latest colon cancer screening. Any testing deemed appropriate by the American Cancer Society is accepted. The Peace Corps uses the information in the Colon Cancer Screening Form to determine if the Applicant currently has colon cancer. Additional instructions are included pertaining to abnormal test results. Indeterminate. • ECG Form General Description of Collection: The Mammogram Form is used for all Applicants who have female breasts and will be 50 years of age or older during service who wish to waive routine mammogram screening during service. If an Applicant waives routine mammogram screening during service, the Applicant’s physician is asked to complete this form in order to make a general assessment of the Applicant’s statistical breast cancer risk and discussed the results with the Applicant VerDate Sep<11>2014 including the potential adverse health consequence of foregoing screening mammography. 21:24 Nov 16, 2016 Jkt 241001 (a) Estimated number of Applicants/physicians. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 575/575. one time. 25 minutes/15 minutes. 240 hours/144 hours. Indeterminate. General Description of Collection: The ECG/EKG Form is used with all Applicants who are 50 years of age or older to provide the Peace Corps with the results of an electrocardiogram. The PO 00000 Frm 00129 Fmt 4703 Sfmt 4703 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. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents Indeterminate. 392/392. one time. 75–105 minutes/30 minutes. 490–686 hours/ 196 hours. General Description of Collection: The Reactive Tuberculin Test Evaluation Form is used when an Applicant reports a history of treatment for active tuberculosis or a history of a positive tuberculosis (TB) test on their Health History Form or if a positive TB test result is noted as a component of the Applicant’s physical examination findings. In these cases, the Applicant is provided a Reactive Tuberculin Test Evaluation Form for the treating physician to complete. The treating physician is asked to document the type and date of a current TB test, TB test history, diagnostic tests if indicated, treatment history, risk assessment for developing active TB, current TB symptoms, and recommendations for further evaluation and treatment. In the case of a positive result on the TB test, a chest x-ray may be required, along with treatment for latent TB. • Insulin Dependent Supplemental Documentation Form (a) Estimated number of Applicants/physicians. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 14/14. one time. 70 minutes/60 minutes. 16 hours/14 hours. Indeterminate. General Description of Collection: The Insulin Dependent Supplemental Documentation Form is used with Applicants who have reported on the Health History Form that they have insulin dependent diabetes. In these cases, the Applicant is provided an Insulin Dependent Supplemental Documentation Form for the treating physician to complete. The Insulin Dependent Supplemental Documentation Form asks the treating physician to document that he or she has discussed with the Applicant medication (insulin) management, E:\FR\FM\17NON1.SGM 17NON1 81182 Federal Register / Vol. 81, No. 222 / Thursday, November 17, 2016 / Notices 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. 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. • Prescription for Eyeglasses Form This notice is issued in Washington, DC, on November 8, 2016. Monique Harris, FOIA/Privacy Act Specialist, Management. (a) Estimated number of Applicants/physicians. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 3,293/3,293. one time. 60 minutes/15 minutes. 3,293 hours/824 hours. Indeterminate. General Description of Collection: The Prescription for Eyeglasses is used with Applicants who have reported on the Health History Form that they use corrective lenses or otherwise have uncorrected vision that is worse than 20/40. In these cases, Applicants are provided a Prescription for Eyeglasses Form for their prescriber to indicate eyeglasses frame measurements, lens instructions, type of lens, gross vision and any special instructions. This form is used in order to enable the Peace Corps to obtain replacement eyeglasses for a Volunteer during service. • Required Peace Corps Immunizations Form asabaliauskas on DSK3SPTVN1PROD with NOTICES (a) Estimated number of Applicants/physicians. (b) Frequency of response ... (c) Estimated average burden per response. (d) Estimated total reporting burden. (e) Estimated annual cost to respondents. 5,600. one time. 60 minutes. 5,600 hours. Indeterminate. General Description of Collection: The Required Peace Corps Immunizations Form is used to informed Applicants of the specific vaccines and/or documented proof of immunity required for medical clearance for the specific country of service. The form advises the Applicant that all other Center for Disease Control (CDC) recommended vaccinations will be administered after arrival in-country. This form assists the Peace Corps with establishing a baseline of the Applicants immunization history and prepare for any additional vaccines recommended for country of service. Request for Comment: Peace Corps invites comments on whether the proposed collections of information are necessary for proper performance of the functions of the Peace Corps, including whether the information will have practical use; the accuracy of the VerDate Sep<11>2014 21:24 Nov 16, 2016 Jkt 241001 [FR Doc. 2016–27565 Filed 11–16–16; 8:45 am] BILLING CODE 6051–01–P3 SECURITIES AND EXCHANGE COMMISSION [Release No. 34–79291; File No. SR– NYSEArca–2016–144] Self-Regulatory Organizations; NYSE Arca, Inc.; Notice of Filing and Immediate Effectiveness of Proposed Rule Change To Amend the NYSE Arca Options Fee Schedule Effective November 3, 2016 November 10, 2016. Pursuant to Section 19(b)(1) 1 of the Securities Exchange Act of 1934 (the ‘‘Act’’) 2 and Rule 19b–4 thereunder,3 notice is hereby given that, on November 3, 2016, NYSE Arca, Inc. (the ‘‘Exchange’’ or ‘‘NYSE Arca’’) filed with the Securities and Exchange Commission (the ‘‘Commission’’) the proposed rule change as described in Items I, II, and III below, which Items have been prepared by the selfregulatory organization. The Commission is publishing this notice to solicit comments on the proposed rule change from interested persons. I. Self-Regulatory Organization’s Statement of the Terms of the Substance of the Proposed Rule Change The Exchange proposes to amend the NYSE Arca Options Fee Schedule (‘‘Fee Schedule’’). The Exchange proposes to implement the fee change effective November 3, 2016. The proposed rule change is available on the Exchange’s Web site at www.nyse.com, at the principal office of the Exchange, and at the Commission’s Public Reference Room. 1 15 U.S.C. 78s(b)(1). U.S.C. 78a. 3 17 CFR 240.19b–4. 2 15 PO 00000 Frm 00130 Fmt 4703 Sfmt 4703 II. Self-Regulatory Organization’s Statement of the Purpose of, and Statutory Basis for, the Proposed Rule Change In its filing with the Commission, the self-regulatory organization included statements concerning the purpose of, and basis for, the proposed rule change and discussed any comments it received on the proposed rule change. The text of those statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in sections A, B, and C below, of the most significant parts of such statements. A. Self-Regulatory Organization’s Statement of the Purpose of, and Statutory Basis for, the Proposed Rule Change 1. Purpose The purpose of this filing is to amend the Fee Schedule effective November 3, 2016. Specifically, the Exchange proposes to (i) modify the qualification for Tier 6 of Customer and Professional Customer Monthly Posting Credit Tiers and Qualifications in Penny Pilot Issues (the ‘‘Posting Tiers’’); and (ii) modify one aspect of the Customer and Professional Customer Incentive Program. Currently, to qualify for Tier 6 of the Posting Tiers, OTP Holders and OTP Firms (‘‘OTPs’’) must execute at least 0.50% of Total Industry Customer equity and ETF option ADV (‘‘TCADV’’) from Customer and Professional Customer posted orders in all issues (‘‘the options component’’), plus executed ADV of 0.70% of U.S. equity market share posted and executed on NYSE Arca Equity Market (‘‘the equity component’’). OTPs that achieve Tier 6 are eligible to receive a $0.48 credit applied to posted electronic Customer and Professional Customer executions in Penny Pilot Issues. In addition, the Customer and Professional Customer Incentive Program (‘‘the Incentive Program’’), which provides OTPs six alternatives to earn additional posting credits ranging from $0.01 to $0.05, currently affords OTPs the ability to earn an additional $0.03 credit on Customer and Professional Customer Posting Credits by meeting the same 0.70% minimum qualification of the equity component as set forth in Tier 6. The Exchange is proposing to modify Tier 6 of the Posting Tiers by reducing the options component from 0.50% TCADV to 0.35% TCADV, while increasing the threshold of the equity component from 0.70% to 0.80% of U.S. E:\FR\FM\17NON1.SGM 17NON1

Agencies

[Federal Register Volume 81, Number 222 (Thursday, November 17, 2016)]
[Notices]
[Pages 81179-81182]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-27565]


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PEACE CORPS


Information Collection Request Submission for OMB Review

AGENCY: Peace Corps.

ACTION: 60-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 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: Submit comments on or before January 17, 2017.

ADDRESSES: Comments should be addressed to Denora Miller, FOIA/Privacy 
Act Officer. 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: 
    Title: Individual Specific Medical Evaluation Forms (15).
    OMB Control Number: 0420-0550.
    Type of Request: Revision/New.
    Affected Public: Individuals/Physicians.
    Respondents Obligation to Reply: Voluntary.
    Respondents: Potential and current volunteers.
    Burden to the Public:

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Asthma Evaluation Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    700/700.
   physicians.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       75 minutes/30 minutes.
   response.
  (d) Estimated total reporting burden.  875 hours/350 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: When an Applicant reports on the 
Health History Form any history of asthma, he or she will be provided 
an Asthma Evaluation Form for the treating physician to complete The 
Asthma Evaluation Form asks for the physician to document the 
Applicant's condition of asthma, including any asthma symptoms, 
triggers, treatments, or limitations or restrictions due to the 
condition. This form will be used as the basis for an individualized 
determination as to whether the Applicant will, with reasonable 
accommodation, be able to perform the essential functions of a Peace 
Corps Volunteer and complete a tour of service without unreasonable 
disruption due to health problems. This form will also be used to 
determine the type of accommodation that may be needed, such as 
placement of the Applicant within reasonable proximity to a hospital in 
case treatment is needed for a severe asthma attack.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Diabetes Diagnosis Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    55/55.
   physicians.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       75 minutes/30 minutes.
   response.
  (d) Estimated total reporting burden.  69 hours/28 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: When an Applicant reports the 
condition of diabetes Type 1 on the Health History Form, the Applicant 
will be provided a Diabetes Diagnosis Form for the treating physician 
to complete. In certain cases, the Applicant may also be asked to have 
the treating physician complete a Diabetes Diagnosis Form if the 
Applicant reports the condition of diabetes Type 2 on the Health 
History Form. The Diabetes Diagnosis Form asks the physician to 
document the diabetes diagnosis, etiology, possible complications, and 
treatment. This form will be used as the basis for an individualized 
determination as to whether the Applicant will, with reasonable 
accommodation, be able to perform the essential functions of a Peace 
Corps Volunteer assignment and complete a tour of service without 
unreasonable disruption due to health problems. This form will also be 
used to determine the type of accommodation that may be needed, such as 
placement

[[Page 81180]]

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.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Transfer of Care--Request for Information Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    1270/1270.
   physicians.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       75 minutes/30 minutes.
   response.
  (d) Estimated total reporting burden.  1588 hours/635 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: When an Applicant reports on the 
Health History Form a medical condition of significant severity (other 
than one covered by another form), he or she may be provided the 
Transfer of Care--Request for Information Form for the treating 
physician to complete. The Transfer of Care--Request for Information 
Form may also be provided to an Applicant whose responses on the Health 
History Form indicate that the Applicant may have an unstable medical 
condition that requires ongoing treatment. The Transfer of Care--
Request for Information Form asks the physician to document the 
diagnosis, current treatment, physical limitations and the likelihood 
of significant progression of the condition over the next three years. 
This form will be used as the basis for an individualized determination 
as to whether the Applicant will, with reasonable accommodation, be 
able to perform the essential functions of a Peace Corps Volunteer 
assignment and complete a tour of service without unreasonable 
disruption due to health problems. This form will also be used to 
determine the type of accommodation (e.g., avoidance of high altitudes 
or proximity to a hospital) that may be needed to manage the 
Applicant's medical condition.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Mental Health Current Evaluation and Treatment Summary Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    1221/1221.
   professional.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       105 minutes/60 minutes.
   response.
  (d) Estimated total reporting burden.  2137 hours/1221 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: The Mental Health Current 
Evaluation Form will be used when an Applicant reports on the Health 
History Form a history of certain serious mental health conditions, 
such as bipolar disorder, schizophrenia, mental health hospitalization, 
attempted suicide or cutting, or treatments or medications related to 
these conditions. In these cases, an Applicant will be provided a 
Mental Health Current Evaluation and Treatment Summary Form for a 
licensed mental health counselor, psychiatrist or psychologist to 
complete. The Mental Health Current Evaluation and Treatment Summary 
Form asks the counselor, psychiatrist or psychologist to document the 
dates and frequency of therapy sessions, clinical diagnoses, symptoms, 
course of treatment, psychotropic medications, mental health history, 
level of functioning, prognosis, risk of exacerbation or recurrence 
while overseas, recommendations for follow up and any concerns that 
would prevent the Applicant from completing 27 months of service 
without unreasonable disruption. A current mental health evaluation 
might be needed if information on the condition is out-dated or 
previous reports on the condition do not provide enough information to 
adequately assess the current status of the condition. This form will 
be used as the basis for an individualized determination as to whether 
the Applicant will, with reasonable accommodation, be able to perform 
the essential functions of a Peace Corps Volunteer and complete a tour 
of service without unreasonable disruption due to health problems. This 
form will also be used to determine the type of accommodation that may 
be needed, such as placement of the Applicant in a country with 
appropriate mental health support.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Functional Abilities Evaluation Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    300/300.
   professional.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       90 minutes/45 minutes.
   response.
  (d) Estimated total reporting burden.  390 hours/225 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: When an Applicant reports on the 
Health History Form a functional ability limitation he or she will be 
provided this form to determine the type of accommodation and/or 
placement program support (e.g., proximity to program site, support 
support devices) that may be needed to manage the Applicant's medical 
condition. This form will be used as the basis for an individualized 
determination as to whether the Applicant will, with reasonable 
accommodation, be able to perform the essential functions of a Peace 
Corps Volunteer assignment and complete a tour of service without 
unreasonable disruption due to health problems.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Eating Disorder Treatment Summary Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    282/282.
   physicians.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       105 minutes/60 minutes.
   response.
  (d) Estimated total reporting burden.  494 hours/282 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: The Eating Disorder Treatment 
Summary will be used when an Applicant reports a past or current eating 
disorder diagnosis in the Health History Form. In these cases the 
Applicant is provided an Eating Disorder Treatment Summary Form for a 
mental health specialist, preferably with eating disorder training, to 
complete. The Eating Disorder Treatment Summary Form asks the mental 
health specialist to document the dates and frequency of therapy 
sessions, clinical diagnoses, presenting problems and precipitating 
factors, symptoms, Applicant's weight over the past three years, 
relevant family history, course of treatment, psychotropic medications, 
mental health history inclusive of eating disorder behaviors, level of 
functioning, prognosis, risk of recurrence in a stressful overseas 
environment, recommendations for follow up, and any concerns that would 
prevent the Applicant from completing 27 months of service without 
unreasonable disruption due to the diagnosis. This form will be used as 
the basis for an individualized determination as to whether the 
Applicant will, with reasonable accommodation, be able to perform the 
essential functions of a Peace Corps Volunteer assignment and complete 
a tour of service without unreasonable disruption due to health 
problems. This form will also be used to determine the type of 
accommodation that may be needed, such as placement of the Applicant in 
a country with appropriate mental health support.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Substance-Related and Addictive Disorders Current Evaluation
 Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    373/373.
   specialist.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       minutes.
   response165 minutes/60.
  (d) Estimated total reporting          .
   burden1026 hours/373 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: The Alcohol/Substance Abuse 
Current

[[Page 81181]]

Evaluation Form is used when an Applicant reports in the Health History 
Form a history of substance abuse (i.e., alcohol or drug related 
problems such as blackouts, daily or heavy drinking patterns or the 
misuse of illegal or prescription drugs) and that this substance abuse 
affects the Applicant's daily living or that the Applicant has ongoing 
symptoms of substance abuse. In these cases, the Applicant is provided 
an Substance-Related and Addictive Disorders Current Evaluation Form 
for a substance abuse specialist to complete. The Substance-Related and 
Addictive Disorders Current Evaluation Form asks the substance abuse 
specialist to document the history of alcohol/substance abuse, dates 
and frequency of any therapy sessions, which alcohol/substance abuse 
assessment tools were administered, mental health diagnoses, 
psychotropic medications, self harm behavior, current clinical 
assessment of alcohol/substance use, clinical observations, risk of 
recurrence in a stressful overseas environment, recommendations for 
follow up, and any concerns that would prevent the Applicant from 
completing a tour of service without unreasonable disruption due to the 
diagnosis. This form will be used as the basis for an individualized 
determination as to whether the Applicant will, with reasonable 
accommodation, be able to perform the essential functions of a Peace 
Corps Volunteer and complete a tour of service without unreasonable 
disruption due to health problems. This form will also be used to 
determine the type of accommodation that may be needed, such as 
placement of the Applicant in a country with appropriate sobriety 
support or counseling support.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Mammogram Waiver Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants...  148.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       105 minutes.
   response.
  (d) Estimated total reporting burden.  259 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: The Mammogram Form is used for 
all Applicants who have female breasts and will be 50 years of age or 
older during service who wish to waive routine mammogram screening 
during service. If an Applicant waives routine mammogram screening 
during service, the Applicant's physician is asked to complete this 
form in order to make a general assessment of the Applicant's 
statistical breast cancer risk and discussed the results with the 
Applicant including the potential adverse health consequence of 
foregoing screening mammography.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Cervical Cancer Screening Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants...  3600/3600.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       40 minutes/30 minutes.
   response.
  (d) Estimated total reporting burden.  2400 hours/1800 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: The Cervical Cancer Screening 
Form is used with all Applicants with a cervix. Prior to medical 
clearance, female Applicants are required to submit a current cervical 
cancer screening examination and Pap cytology report based the American 
Society for Colploscopy and Cervical Pathology (ASCCP) screening time-
line for their age and Pap history. This form assists the Peace Corps 
in determining whether an Applicant with mildly abnormal Pap history 
will need to be placed in a country with appropriate support.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Colon Cancer Screening Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants...  575.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       60 minutes--165 minutes.
   response.
  (d) Estimated total reporting burden.  575 hours--1581 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: The Colon Cancer Screening Form 
is used with all Applicants who are 50 years of age or older to provide 
the Peace Corps with the results of the Applicant's latest colon cancer 
screening. Any testing deemed appropriate by the American Cancer 
Society is accepted. The Peace Corps uses the information in the Colon 
Cancer Screening Form to determine if the Applicant currently has colon 
cancer. Additional instructions are included pertaining to abnormal 
test results.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 ECG Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    575/575.
   physicians.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       25 minutes/15 minutes.
   response.
  (d) Estimated total reporting burden.  240 hours/144 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: The ECG/EKG Form is used with 
all Applicants who are 50 years of age or older to provide the Peace 
Corps with the results of an electrocardiogram. The Peace Corps uses 
the information in the electrocardiogram to assess whether the 
Applicant has any cardiac abnormalities that might affect the 
Applicant's service. Additional instructions are included pertaining to 
abnormal test results. The electrocardiogram is performed as part of 
the Applicant's physical examination.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Reactive Tuberculin Test Evaluation Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    392/392.
   physicians.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       75-105 minutes/30 minutes.
   response.
  (d) Estimated total reporting burden.  490-686 hours/196 hours.
  (e) Estimated annual cost to
   respondents Indeterminate.
------------------------------------------------------------------------

    General Description of Collection: The Reactive Tuberculin Test 
Evaluation Form is used when an Applicant reports a history of 
treatment for active tuberculosis or a history of a positive 
tuberculosis (TB) test on their Health History Form or if a positive TB 
test result is noted as a component of the Applicant's physical 
examination findings. In these cases, the Applicant is provided a 
Reactive Tuberculin Test Evaluation Form for the treating physician to 
complete. The treating physician is asked to document the type and date 
of a current TB test, TB test history, diagnostic tests if indicated, 
treatment history, risk assessment for developing active TB, current TB 
symptoms, and recommendations for further evaluation and treatment. In 
the case of a positive result on the TB test, a chest x-ray may be 
required, along with treatment for latent TB.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Insulin Dependent Supplemental Documentation Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    14/14.
   physicians.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       70 minutes/60 minutes.
   response.
  (d) Estimated total reporting burden.  16 hours/14 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: The Insulin Dependent 
Supplemental Documentation Form is used with Applicants who have 
reported on the Health History Form that they have insulin dependent 
diabetes. In these cases, the Applicant is provided an Insulin 
Dependent Supplemental Documentation Form for the treating physician to 
complete. The Insulin Dependent Supplemental Documentation Form asks 
the treating physician to document that he or she has discussed with 
the Applicant medication (insulin) management,

[[Page 81182]]

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/    3,293/3,293.
   physicians.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       60 minutes/15 minutes.
   response.
  (d) Estimated total reporting burden.  3,293 hours/824 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: The Prescription for Eyeglasses 
is used with Applicants who have reported on the Health History Form 
that they use corrective lenses or otherwise have uncorrected vision 
that is worse than 20/40. In these cases, Applicants are provided a 
Prescription for Eyeglasses Form for their prescriber to indicate 
eyeglasses frame measurements, lens instructions, type of lens, gross 
vision and any special instructions. This form is used in order to 
enable the Peace Corps to obtain replacement eyeglasses for a Volunteer 
during service.

------------------------------------------------------------------------
 
------------------------------------------------------------------------
 Required Peace Corps Immunizations Form
------------------------------------------------------------------------
  (a) Estimated number of Applicants/    5,600.
   physicians.
  (b) Frequency of response............  one time.
  (c) Estimated average burden per       60 minutes.
   response.
  (d) Estimated total reporting burden.  5,600 hours.
  (e) Estimated annual cost to           Indeterminate.
   respondents.
------------------------------------------------------------------------

    General Description of Collection: The Required Peace Corps 
Immunizations Form is used to informed Applicants of the specific 
vaccines and/or documented proof of immunity required for medical 
clearance for the specific country of service. The form advises the 
Applicant that all other Center for Disease Control (CDC) recommended 
vaccinations will be administered after arrival in-country. This form 
assists the Peace Corps with establishing a baseline of the Applicants 
immunization history and prepare for any additional vaccines 
recommended for country of service.
    Request for Comment: Peace Corps invites comments on whether the 
proposed collections of information are necessary for proper 
performance of the functions of the Peace Corps, including whether the 
information will have practical use; the accuracy of the agency's 
estimate of the burden of the proposed collection of information, 
including the validity of the information to be collected; and, ways to 
minimize the burden of the collection of information on those who are 
to respond, including through the use of automated collection 
techniques, when appropriate, and other forms of information 
technology.

    This notice is issued in Washington, DC, on November 8, 2016.
Monique Harris,
FOIA/Privacy Act Specialist, Management.
[FR Doc. 2016-27565 Filed 11-16-16; 8:45 am]
BILLING CODE 6051-01-P3