Information Collection Request; Submission for OMB Review, 9402-9405 [2017-02369]
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9402
Federal Register / Vol. 82, No. 23 / Monday, February 6, 2017 / Notices
Commission’s rules and regulations.
The Commission has made appropriate
findings as required by the Act and the
Commission’s rules and regulations in
10 CFR chapter I, which are set forth in
the license amendment.
A notice of consideration of issuance
of amendment to facility operating
license or combined license, as
applicable, proposed no significant
hazards consideration determination,
and an opportunity for a hearing in
connection with these actions, was
published in the Federal Register on
October 11, 2016 (81 FR 70175). No
comments were received during the 30day comment period.
The Commission has determined that
these amendments satisfy the criteria for
categorical exclusion in accordance
with 10 CFR 51.22. Therefore, pursuant
to 10 CFR 51.22(b), no environmental
impact statement or environmental
assessment need be prepared for these
amendments.
IV. Conclusion
Using the reasons set forth in the
combined safety evaluation, the staff
granted the exemption and issued the
amendment that the licensee requested
on September 9, 2016. The exemption
and amendment were issued on
December 16, 2016, as part of a
combined package to the licensee
(ADAMS Accession No. ML16327A606).
Dated at Rockville, Maryland, this 31st day
of January 2017.
For the Nuclear Regulatory Commission.
Jennifer Dixon-Herrity,
Chief, Licensing Branch 4, Division of New
Reactor Licensing, Office of New Reactors.
[FR Doc. 2017–02414 Filed 2–3–17; 8:45 am]
BILLING CODE 7590–01–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 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
March 8, 2017.
sradovich on DSK3GMQ082PROD with NOTICES
SUMMARY:
VerDate Sep<11>2014
16:03 Feb 03, 2017
Jkt 241001
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.
ADDRESSES:
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: 700/700.
(b) Frequency of response: one time.
(c) Estimated average burden per
response: 75 minutes/30 minutes.
(d) Estimated total reporting burden:
875 hours/350 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection:
When an Applicant reports on the
Health History Form any history of
asthma, he or she will be provided an
Asthma Evaluation Form for the treating
physician to complete. The Asthma
Evaluation Form asks for the physician
to document the Applicant’s condition
of asthma, including any asthma
symptoms, triggers, treatments, or
limitations or restrictions due to the
condition. This form will be used as the
basis for an individualized
determination as to whether the
Applicant will, with reasonable
accommodation, be able to perform the
essential functions of a Peace Corps
Volunteer and complete a tour of service
without unreasonable disruption due to
health problems. This form will also be
used to determine the type of
accommodation that may be needed,
such as placement of the Applicant
within reasonable proximity to a
hospital in case treatment is needed for
a severe asthma attack.
• Diabetes Diagnosis Form
(a) Estimated number of Applicants/
physicians: 55/55.
(b) Frequency of response: one time.
(c) Estimated average burden per
response: 75 minutes/30 minutes.
(d) Estimated total reporting burden:
69 hours/28 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
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General Description of Collection:
When an Applicant reports the
condition of diabetes Type 1 on the
Health History Form, the Applicant will
be provided a Diabetes Diagnosis Form
for the treating physician to complete.
In certain cases, the Applicant may also
be asked to have the treating physician
complete a Diabetes Diagnosis Form if
the Applicant reports the condition of
diabetes Type 2 on the Health History
Form. The Diabetes Diagnosis Form asks
the physician to document the diabetes
diagnosis, etiology, possible
complications, and treatment. This form
will be used as the basis for an
individualized determination as to
whether the Applicant will, with
reasonable accommodation, be able to
perform the essential functions of a
Peace Corps Volunteer assignment and
complete a tour of service without
unreasonable disruption due to health
problems. This form will also be used to
determine the type of accommodation
that may be needed, such as placement
of an Applicant who requires the use of
insulin in order to ensure that adequate
insulin storage facilities are available at
the Applicant’s site.
• Transfer of Care—Request for
Information Form
(a) Estimated number of Applicants/
physicians: 1270/1270.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 75 minutes/30 minutes.
(d) Estimated total reporting burden:
1588 hours/635 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection:
When an Applicant reports on the
Health History Form a medical
condition of significant severity (other
than one covered by another form), he
or she may be provided the Transfer of
Care—Request for Information Form for
the treating physician to complete. The
Transfer of Care—Request for
Information Form may also be provided
to an Applicant whose responses on the
Health History Form indicate that the
Applicant may have an unstable
medical condition that requires ongoing
treatment. The Transfer of Care—
Request for Information Form asks the
physician to document the diagnosis,
current treatment, physical limitations
and the likelihood of significant
progression of the condition over the
next three years. This form will be used
as the basis for an individualized
determination as to whether the
Applicant will, with reasonable
accommodation, be able to perform the
essential functions of a Peace Corps
Volunteer assignment and complete a
tour of service without unreasonable
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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/
professional: 1221/1221.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 105 minutes/60 minutes.
(d) Estimated total reporting burden:
2137 hours/1221 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
Mental Health Current Evaluation Form
will be used when an Applicant reports
on the Health History Form a history of
certain serious mental health
conditions, such as bipolar disorder,
schizophrenia, mental health
hospitalization, attempted suicide or
cutting, or treatments or medications
related to these conditions. In these
cases, an Applicant will be provided a
Mental Health Current Evaluation and
Treatment Summary Form for a licensed
mental health counselor, psychiatrist or
psychologist to complete. The Mental
Health Current Evaluation and
Treatment Summary Form asks the
counselor, psychiatrist or psychologist
to document the dates and frequency of
therapy sessions, clinical diagnoses,
symptoms, course of treatment,
psychotropic medications, mental
health history, level of functioning,
prognosis, risk of exacerbation or
recurrence while overseas,
recommendations for follow up and any
concerns that would prevent the
Applicant from completing 27 months
of service without unreasonable
disruption. A current mental health
evaluation might be needed if
information on the condition is 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
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(a) Estimated number of Applicants/
professional: 300/300.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 90 minutes/45 minutes.
(d) Estimated total reporting burden:
390 hours/225 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection:
When an Applicant reports on the
Health History Form a functional ability
limitation he or she will be provided
this form to determine the type of
accommodation and/or placement
program support (e.g., proximity to
program site, support support devices)
that may be needed to manage the
Applicant’s medical condition. This
form will be used as the basis for an
individualized determination as to
whether the Applicant will, with
reasonable accommodation, be able to
perform the essential functions of a
Peace Corps Volunteer assignment and
complete a tour of service without
unreasonable disruption due to health
problems.
• Eating Disorder Treatment
Summary Form
(a) Estimated number of Applicants/
physicians: 282/282.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 105 minutes/60 minutes.
(d) Estimated total reporting burden:
494 hours/282 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
Eating Disorder Treatment Summary
will be used when an Applicant reports
a past or current eating disorder
diagnosis in the Health History Form. In
these cases the Applicant is provided an
Eating Disorder Treatment Summary
Form for a mental health specialist,
preferably with eating disorder training,
to complete. The Eating Disorder
Treatment Summary Form asks the
mental health specialist to document
the dates and frequency of therapy
sessions, clinical diagnoses, presenting
problems and precipitating factors,
symptoms, Applicant’s weight over the
past three years, relevant family history,
course of treatment, psychotropic
medications, mental health history
inclusive of eating disorder behaviors,
level of functioning, prognosis, risk of
recurrence in a stressful overseas
environment, recommendations for
follow up, and any concerns that would
prevent the Applicant from completing
27 months of service without
unreasonable disruption due to the
diagnosis. This form will be used as the
basis for an individualized
determination as to whether the
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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: 373/373.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 165 minutes/60 minutes.
(d) Estimated total reporting burden:
1026 hours/373 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
Alcohol/Substance Abuse Current
Evaluation Form is used when an
Applicant reports in the Health History
Form a history of substance abuse (i.e.,
alcohol or drug related problems such as
blackouts, daily or heavy drinking
patterns or the misuse of illegal or
prescription drugs) and that this
substance abuse affects the Applicant’s
daily living or that the Applicant has
ongoing symptoms of substance abuse.
In these cases, the Applicant is provided
an Substance-Related and Addictive
Disorders Current Evaluation Form for a
substance abuse specialist to complete.
The Substance-Related and Addictive
Disorders Current Evaluation Form asks
the substance abuse specialist to
document the history of alcohol/
substance abuse, dates and frequency of
any therapy sessions, which alcohol/
substance abuse assessment tools were
administered, mental health diagnoses,
psychotropic medications, self harm
behavior, current clinical assessment of
alcohol/substance use, clinical
observations, risk of recurrence in a
stressful overseas environment,
recommendations for follow up, and
any concerns that would prevent the
Applicant from completing a tour of
service without unreasonable disruption
due to the diagnosis. This form will be
used as the basis for an individualized
determination as to whether the
Applicant will, with reasonable
accommodation, be able to perform the
essential functions of a Peace Corps
Volunteer and complete a tour of service
without unreasonable disruption due to
health problems. This form will also be
used to determine the type of
accommodation that may be needed,
such as placement of the Applicant in
a country with appropriate sobriety
support or counseling support.
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• Mammogram Waiver Form
(a) Estimated number of Applicants:
148.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 105 minutes.
(d) Estimated total reporting burden:
259 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
Mammogram Form is used for all
Applicants who have female breasts and
will be 50 years of age or older during
service who wish to waive routine
mammogram screening during service.
If an Applicant waives routine
mammogram screening during service,
the Applicant’s physician is asked to
complete this form in order to make a
general assessment of the Applicant’s
statistical breast cancer risk and
discussed the results with the Applicant
including the potential adverse health
consequence of foregoing screening
mammography.
• Cervical Cancer Screening Form
(a) Estimated number of Applicants:
3600/3600.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 40 minutes/30 minutes.
(d) Estimated total reporting burden:
2400 hours/1800 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
Cervical Cancer Screening Form is used
with all Applicants with a cervix. Prior
to medical clearance, female Applicants
are required to submit a current cervical
cancer screening examination and Pap
cytology report based the American
Society for Colploscopy and Cervical
Pathology (ASCCP) screening time-line
for their age and Pap history. This form
assists the Peace Corps in determining
whether an Applicant with mildly
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
response: 60 minutes–165 minutes.
(d) Estimated total reporting burden:
575 hours–1581 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
Colon Cancer Screening Form is used
with all Applicants who are 50 years of
age or older to provide the Peace Corps
with the results of the Applicant’s latest
colon cancer screening. Any testing
deemed appropriate by the American
Cancer Society is accepted. The Peace
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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: 575/575.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 25 minutes/15 minutes.
(d) Estimated total reporting burden:
240 hours/144 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
ECG/EKG Form is used with all
Applicants who are 50 years of age or
older to provide the Peace Corps with
the results of an electrocardiogram. The
Peace Corps uses the information in the
electrocardiogram to assess whether the
Applicant has any cardiac abnormalities
that might affect the Applicant’s service.
Additional instructions are included
pertaining to abnormal test results. The
electrocardiogram is performed as part
of the Applicant’s physical examination.
• Reactive Tuberculin Test
Evaluation Form
(a) Estimated number of Applicants/
physicians: 392/392.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 75–105 minutes/30 minutes.
(d) Estimated total reporting burden:
490–686 hours/196 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
Reactive Tuberculin Test Evaluation
Form is used when an Applicant reports
a history of treatment for active
tuberculosis or a history of a positive
tuberculosis (TB) test on their Health
History Form or if a positive TB test
result is noted as a component of the
Applicant’s physical examination
findings. In these cases, the Applicant is
provided a Reactive Tuberculin Test
Evaluation Form for the treating
physician to complete. The treating
physician is asked to document the type
and date of a current TB test, TB test
history, diagnostic tests if indicated,
treatment history, risk assessment for
developing active TB, current TB
symptoms, and recommendations for
further evaluation and treatment. In the
case of a positive result on the TB test,
a chest x-ray may be required, along
with treatment for latent TB.
• Insulin Dependent Supplemental
Documentation Form
(a) Estimated number of Applicants/
physicians: 14/14.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 70 minutes/60 minutes.
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(d) Estimated total reporting burden:
16 hours/14 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
Insulin Dependent Supplemental
Documentation Form is used with
Applicants who have reported on the
Health History Form that they have
insulin dependent diabetes. In these
cases, the Applicant is provided an
Insulin Dependent Supplemental
Documentation Form for the treating
physician to complete. The Insulin
Dependent Supplemental
Documentation Form asks the treating
physician to document that he or she
has discussed with the Applicant
medication (insulin) management,
including whether an insulin pump is
required, as well as the care and
maintenance of all required diabetes
related monitors and equipment. This
form assists the Peace Corps in
determining whether the Applicant will
be in need of insulin storage while in
service and, if so, will assist the Peace
Corps in determining an appropriate
placement for the Applicant.
• Prescription for Eyeglasses Form
(a) Estimated number of Applicants/
physicians: 3,293/3,293.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 60 minutes/15 minutes.
(d) Estimated total reporting burden:
3,293 hours/824 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
Prescription for Eyeglasses is used with
Applicants who have reported on the
Health History Form that they use
corrective lenses or otherwise have
uncorrected vision that is worse than
20/40. In these cases, Applicants are
provided a Prescription for Eyeglasses
Form for their prescriber to indicate
eyeglasses frame measurements, lens
instructions, type of lens, gross vision
and any special instructions. This form
is used in order to enable the Peace
Corps to obtain replacement eyeglasses
for a Volunteer during service.
• Required Peace Corps
Immunizations Form
(a) Estimated number of Applicants/
physicians: 5,600.
(b) Frequency of response: One time.
(c) Estimated average burden per
response: 60 minutes.
(d) Estimated total reporting burden:
5,600 hours.
(e) Estimated annual cost to
respondents: Indeterminate.
General Description of Collection: The
Required Peace Corps Immunizations
Form is used to informed Applicants of
the specific vaccines and/or
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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 Applicant’s 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
January 31, 2017.
Denora Miller,
FOIA/Privacy Act Officer, Management.
[FR Doc. 2017–02369 Filed 2–3–17; 8:45 am]
BILLING CODE 6051–01–P
PEACE CORPS
Information Collection Request;
Submission for OMB Review
Peace Corps.
ACTION: 30-day notice and request for
comments.
AGENCY:
The Peace Corps will be
submitting the following information
collection request to the Office of
Management and Budget (OMB) for
review and approval. The purpose of
this notice is to allow 30 days for public
comment in the Federal Register
preceding submission to OMB. We are
conducting this process in accordance
with the Paperwork Reduction Act of
1995 (44 U.S.C. Chapter 35).
DATES: Submit comments on or before
March 8, 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.
sradovich on DSK3GMQ082PROD with NOTICES
SUMMARY:
VerDate Sep<11>2014
16:03 Feb 03, 2017
Jkt 241001
SUPPLEMENTARY INFORMATION:
Title: Peace Corps Report of Physical
Examination (PC 1790S).
OMB Control Number: 0420–0549.
Type of Request: Revision.
Affected Public: Individuals/
Physicians.
Respondents Obligation to Reply:
Voluntary.
Respondents: Potential and current
volunteers.
Burden to the Public:
a. Estimated number
of respondents.
b. Estimated average
burden per response.
c. Frequency of response.
d. Annual reporting
burden.
5,600/5,600.
45 min/90 min.
One time.
4,200 hours/8,400
hours.
General Description of Collection: The
information in this form will be used by
the Peace Corps Office of Medical
Services to determine whether an
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 and,
if so, to establish the level of medical
and other support, if any, that may be
required to reasonably accommodate the
Applicant. The information in this form
is also used as a baseline assessment for
the Peace Corps Medical Officers
overseas who are responsible for the
Volunteer’s medical care. Finally, the
Peace Corps may use the information in
this form as a point of reference in the
event that, after completion of the
Applicant’s service as a Volunteer, he or
she makes a worker’s compensation
claim under the Federal Employee
Compensation Act (FECA).
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.
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9405
This notice is issued in Washington, DC on
January 31, 2017.
Denora Miller,
FOIA/Privacy Act Officer, Management.
[FR Doc. 2017–02370 Filed 2–3–17; 8:45 am]
BILLING CODE 6051–01–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
April 7, 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: Global Health Service
Application.
OMB Control Number: 0420–0005.
Type of Request: New.
Affected Public: Individuals.
Respondents Obligation to Reply:
Voluntary.
Respondents: Potential Volunteers.
Burden to the Public:
Estimated burden (hours) of the
collection of information:
a. Number of respondents: 200.
b. Frequency of response: One time.
c. Completion time: 60 minutes.
d. Annual burden hours: 200 hours.
General Description of Collection: The
Global Health Service Partnership
Application (hereinafter ‘‘the
Application’’) is necessary to recruit
qualified volunteers to serve in Peace
Corps Response, as Global Health
Service Partnership Volunteers to build
institutional capacity and help
strengthen the quality of medical and
nursing education. Applicants are
selected based on their qualifications for
a specific Volunteer assignment.
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]]>Agencies
[Federal Register Volume 82, Number 23 (Monday, February 6, 2017)]
[Notices]
[Pages 9402-9405]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-02369]
=======================================================================
-----------------------------------------------------------------------
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 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 March 8, 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/physicians: 700/700.
(b) Frequency of response: one time.
(c) Estimated average burden per response: 75 minutes/30 minutes.
(d) Estimated total reporting burden: 875 hours/350 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: When an Applicant reports on the
Health History Form any history of asthma, he or she will be provided
an Asthma Evaluation Form for the treating physician to complete. The
Asthma Evaluation Form asks for the physician to document the
Applicant's condition of asthma, including any asthma symptoms,
triggers, treatments, or limitations or restrictions due to the
condition. This form will be used as the basis for an individualized
determination as to whether the Applicant will, with reasonable
accommodation, be able to perform the essential functions of a Peace
Corps Volunteer and complete a tour of service without unreasonable
disruption due to health problems. This form will also be used to
determine the type of accommodation that may be needed, such as
placement of the Applicant within reasonable proximity to a hospital in
case treatment is needed for a severe asthma attack.
Diabetes Diagnosis Form
(a) Estimated number of Applicants/physicians: 55/55.
(b) Frequency of response: one time.
(c) Estimated average burden per response: 75 minutes/30 minutes.
(d) Estimated total reporting burden: 69 hours/28 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: When an Applicant reports the
condition of diabetes Type 1 on the Health History Form, the Applicant
will be provided a Diabetes Diagnosis Form for the treating physician
to complete. In certain cases, the Applicant may also be asked to have
the treating physician complete a Diabetes Diagnosis Form if the
Applicant reports the condition of diabetes Type 2 on the Health
History Form. The Diabetes Diagnosis Form asks the physician to
document the diabetes diagnosis, etiology, possible complications, and
treatment. This form will be used as the basis for an individualized
determination as to whether the Applicant will, with reasonable
accommodation, be able to perform the essential functions of a Peace
Corps Volunteer assignment and complete a tour of service without
unreasonable disruption due to health problems. This form will also be
used to determine the type of accommodation that may be needed, such as
placement of an Applicant who requires the use of insulin in order to
ensure that adequate insulin storage facilities are available at the
Applicant's site.
Transfer of Care--Request for Information Form
(a) Estimated number of Applicants/physicians: 1270/1270.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 75 minutes/30 minutes.
(d) Estimated total reporting burden: 1588 hours/635 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: When an Applicant reports on the
Health History Form a medical condition of significant severity (other
than one covered by another form), he or she may be provided the
Transfer of Care--Request for Information Form for the treating
physician to complete. The Transfer of Care--Request for Information
Form may also be provided to an Applicant whose responses on the Health
History Form indicate that the Applicant may have an unstable medical
condition that requires ongoing treatment. The Transfer of Care--
Request for Information Form asks the physician to document the
diagnosis, current treatment, physical limitations and the likelihood
of significant progression of the condition over the next three years.
This form will be used as the basis for an individualized determination
as to whether the Applicant will, with reasonable accommodation, be
able to perform the essential functions of a Peace Corps Volunteer
assignment and complete a tour of service without unreasonable
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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/professional: 1221/1221.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 105 minutes/60 minutes.
(d) Estimated total reporting burden: 2137 hours/1221 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The Mental Health Current
Evaluation Form will be used when an Applicant reports on the Health
History Form a history of certain serious mental health conditions,
such as bipolar disorder, schizophrenia, mental health hospitalization,
attempted suicide or cutting, or treatments or medications related to
these conditions. In these cases, an Applicant will be provided a
Mental Health Current Evaluation and Treatment Summary Form for a
licensed mental health counselor, psychiatrist or psychologist to
complete. The Mental Health Current Evaluation and Treatment Summary
Form asks the counselor, psychiatrist or psychologist to document the
dates and frequency of therapy sessions, clinical diagnoses, symptoms,
course of treatment, psychotropic medications, mental health history,
level of functioning, prognosis, risk of exacerbation or recurrence
while overseas, recommendations for follow up and any concerns that
would prevent the Applicant from completing 27 months of service
without unreasonable disruption. A current mental health evaluation
might be needed if information on the condition is out-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/professional: 300/300.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 90 minutes/45 minutes.
(d) Estimated total reporting burden: 390 hours/225 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: When an Applicant reports on the
Health History Form a functional ability limitation he or she will be
provided this form to determine the type of accommodation and/or
placement program support (e.g., proximity to program site, support
support devices) that may be needed to manage the Applicant's medical
condition. This form will be used as the basis for an individualized
determination as to whether the Applicant will, with reasonable
accommodation, be able to perform the essential functions of a Peace
Corps Volunteer assignment and complete a tour of service without
unreasonable disruption due to health problems.
Eating Disorder Treatment Summary Form
(a) Estimated number of Applicants/physicians: 282/282.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 105 minutes/60 minutes.
(d) Estimated total reporting burden: 494 hours/282 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The Eating Disorder Treatment
Summary will be used when an Applicant reports a past or current eating
disorder diagnosis in the Health History Form. In these cases the
Applicant is provided an Eating Disorder Treatment Summary Form for a
mental health specialist, preferably with eating disorder training, to
complete. The Eating Disorder Treatment Summary Form asks the mental
health specialist to document the dates and frequency of therapy
sessions, clinical diagnoses, presenting problems and precipitating
factors, symptoms, Applicant's weight over the past three years,
relevant family history, course of treatment, psychotropic medications,
mental health history inclusive of eating disorder behaviors, level of
functioning, prognosis, risk of recurrence in a stressful overseas
environment, recommendations for follow up, and any concerns that would
prevent the Applicant from completing 27 months of service without
unreasonable disruption due to the diagnosis. This form will be used as
the basis for an individualized determination as to whether the
Applicant will, with reasonable accommodation, be able to perform the
essential functions of a Peace Corps Volunteer assignment and complete
a tour of service without unreasonable disruption due to health
problems. This form will also be used to determine the type of
accommodation that may be needed, such as placement of the Applicant in
a country with appropriate mental health support.
Substance-Related and Addictive Disorders Current
Evaluation Form
(a) Estimated number of Applicants/specialist: 373/373.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 165 minutes/60 minutes.
(d) Estimated total reporting burden: 1026 hours/373 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The Alcohol/Substance Abuse
Current Evaluation Form is used when an Applicant reports in the Health
History Form a history of substance abuse (i.e., alcohol or drug
related problems such as blackouts, daily or heavy drinking patterns or
the misuse of illegal or prescription drugs) and that this substance
abuse affects the Applicant's daily living or that the Applicant has
ongoing symptoms of substance abuse. In these cases, the Applicant is
provided an Substance-Related and Addictive Disorders Current
Evaluation Form for a substance abuse specialist to complete. The
Substance-Related and Addictive Disorders Current Evaluation Form asks
the substance abuse specialist to document the history of alcohol/
substance abuse, dates and frequency of any therapy sessions, which
alcohol/substance abuse assessment tools were administered, mental
health diagnoses, psychotropic medications, self harm behavior, current
clinical assessment of alcohol/substance use, clinical observations,
risk of recurrence in a stressful overseas environment, recommendations
for follow up, and any concerns that would prevent the Applicant from
completing a tour of service without unreasonable disruption due to the
diagnosis. This form will be used as the basis for an individualized
determination as to whether the Applicant will, with reasonable
accommodation, be able to perform the essential functions of a Peace
Corps Volunteer and complete a tour of service without unreasonable
disruption due to health problems. This form will also be used to
determine the type of accommodation that may be needed, such as
placement of the Applicant in a country with appropriate sobriety
support or counseling support.
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Mammogram Waiver Form
(a) Estimated number of Applicants: 148.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 105 minutes.
(d) Estimated total reporting burden: 259 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The Mammogram Form is used for
all Applicants who have female breasts and will be 50 years of age or
older during service who wish to waive routine mammogram screening
during service. If an Applicant waives routine mammogram screening
during service, the Applicant's physician is asked to complete this
form in order to make a general assessment of the Applicant's
statistical breast cancer risk and discussed the results with the
Applicant including the potential adverse health consequence of
foregoing screening mammography.
Cervical Cancer Screening Form
(a) Estimated number of Applicants: 3600/3600.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 40 minutes/30 minutes.
(d) Estimated total reporting burden: 2400 hours/1800 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The Cervical Cancer Screening
Form is used with all Applicants with a cervix. Prior to medical
clearance, female Applicants are required to submit a current cervical
cancer screening examination and Pap cytology report based the American
Society for Colploscopy and Cervical Pathology (ASCCP) screening time-
line for their age and Pap history. This form assists the Peace Corps
in determining whether an Applicant with mildly 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 response: 60 minutes-165 minutes.
(d) Estimated total reporting burden: 575 hours-1581 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The Colon Cancer Screening Form
is used with all Applicants who are 50 years of age or older to provide
the Peace Corps with the results of the Applicant's latest colon cancer
screening. Any testing deemed appropriate by the American Cancer
Society is accepted. The Peace Corps uses the information in the Colon
Cancer Screening Form to determine if the Applicant currently has colon
cancer. Additional instructions are included pertaining to abnormal
test results.
ECG Form
(a) Estimated number of Applicants/physicians: 575/575.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 25 minutes/15 minutes.
(d) Estimated total reporting burden: 240 hours/144 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The ECG/EKG Form is used with
all Applicants who are 50 years of age or older to provide the Peace
Corps with the results of an electrocardiogram. The Peace Corps uses
the information in the electrocardiogram to assess whether the
Applicant has any cardiac abnormalities that might affect the
Applicant's service. Additional instructions are included pertaining to
abnormal test results. The electrocardiogram is performed as part of
the Applicant's physical examination.
Reactive Tuberculin Test Evaluation Form
(a) Estimated number of Applicants/physicians: 392/392.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 75-105 minutes/30
minutes.
(d) Estimated total reporting burden: 490-686 hours/196 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The Reactive Tuberculin Test
Evaluation Form is used when an Applicant reports a history of
treatment for active tuberculosis or a history of a positive
tuberculosis (TB) test on their Health History Form or if a positive TB
test result is noted as a component of the Applicant's physical
examination findings. In these cases, the Applicant is provided a
Reactive Tuberculin Test Evaluation Form for the treating physician to
complete. The treating physician is asked to document the type and date
of a current TB test, TB test history, diagnostic tests if indicated,
treatment history, risk assessment for developing active TB, current TB
symptoms, and recommendations for further evaluation and treatment. In
the case of a positive result on the TB test, a chest x-ray may be
required, along with treatment for latent TB.
Insulin Dependent Supplemental Documentation Form
(a) Estimated number of Applicants/physicians: 14/14.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 70 minutes/60 minutes.
(d) Estimated total reporting burden: 16 hours/14 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The Insulin Dependent
Supplemental Documentation Form is used with Applicants who have
reported on the Health History Form that they have insulin dependent
diabetes. In these cases, the Applicant is provided an Insulin
Dependent Supplemental Documentation Form for the treating physician to
complete. The Insulin Dependent Supplemental Documentation Form asks
the treating physician to document that he or she has discussed with
the Applicant medication (insulin) management, including whether an
insulin pump is required, as well as the care and maintenance of all
required diabetes related monitors and equipment. This form assists the
Peace Corps in determining whether the Applicant will be in need of
insulin storage while in service and, if so, will assist the Peace
Corps in determining an appropriate placement for the Applicant.
Prescription for Eyeglasses Form
(a) Estimated number of Applicants/physicians: 3,293/3,293.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 60 minutes/15 minutes.
(d) Estimated total reporting burden: 3,293 hours/824 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The Prescription for Eyeglasses
is used with Applicants who have reported on the Health History Form
that they use corrective lenses or otherwise have uncorrected vision
that is worse than 20/40. In these cases, Applicants are provided a
Prescription for Eyeglasses Form for their prescriber to indicate
eyeglasses frame measurements, lens instructions, type of lens, gross
vision and any special instructions. This form is used in order to
enable the Peace Corps to obtain replacement eyeglasses for a Volunteer
during service.
Required Peace Corps Immunizations Form
(a) Estimated number of Applicants/physicians: 5,600.
(b) Frequency of response: One time.
(c) Estimated average burden per response: 60 minutes.
(d) Estimated total reporting burden: 5,600 hours.
(e) Estimated annual cost to respondents: Indeterminate.
General Description of Collection: The Required Peace Corps
Immunizations Form is used to informed Applicants of the specific
vaccines and/or
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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 Applicant's 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 January 31, 2017.
Denora Miller,
FOIA/Privacy Act Officer, Management.
[FR Doc. 2017-02369 Filed 2-3-17; 8:45 am]
BILLING CODE 6051-01-P
