2013-28729. 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:

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

ADDRESSES:

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

FOR FURTHER INFORMATION CONTACT:

Denora Miller at Peace Corps address above.

SUPPLEMENTARY INFORMATION:

Volunteers serve in developing countries where western-style healthcare is often not available. Volunteers are placed in remote locations where they may suffer hardship because they have no access to running water and/or electricity. They also may be placed in locations with extreme environmental conditions related to cold, heat or high altitude and they may be exposed to diseases not generally found in the U.S. Volunteers may be placed many hours from the Peace Corps medical office and not have easy access to any health care provider. Therefore, a thorough review of an Applicant's past medical history is an essential first step to determine their suitability for service in Peace Corps.

The forms listed below may be sent to an individual Applicant at one of the following times in the medical review process: (1) After the Applicant completes the Health History Form and receives a nomination; (2) after a Peace Corps nurse reviews the Applicant's Health History Form and any completed forms previously requested; or (3) at the time of the Applicant's physical examination. The information contained in the specific medical evaluation forms will be used to make an individualized determination as to whether an Applicant for Volunteer service will, with reasonable accommodation, be able to meet the essential eligibility requirements for a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems.

Method: Applicants gain access to the forms via a secure online portal. Applicants will have to download the forms for their health care providers to complete. Completed forms can be scanned and uploaded back into the Applicant's secure Peace Corps online portal or they can be faxed or mailed to the Peace Corps Office of Medical Services.

Title: Individual Specific Medical Evaluation Forms (16).

OMB Control Number: 0420-0550.

Type of Request: Extension without change of a currently approved collection.

Affected Public: Individuals/Physicians.

Respondents' Obligation to Reply: Voluntary.

Burden to the Public

• Allergy Treatment Form

(a) Estimated number of Applicants/physicians: 100/100.

(b) Frequency of response: one time.

(c) Estimated average burden per response: 20 minutes/10 minutes.

(d) Estimated total reporting burden: 33.3 hours/16.7 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: When an Applicant reports that he or she is currently receiving allergy shot treatments, Peace Corps provides the Applicant with an Allergy Treatment Form for his or her treating physician to complete. The Peace Corps is not able to arrange for Volunteers to receive allergy shots during their Peace Corps service. Peace Corps Volunteers generally serve in areas that are isolated and have limited access to Western-trained providers and health care systems. The Applicant completes the form after discussing with his or her physician whether the Applicant will be able to live overseas for 27 months of Peace Corps service without receiving allergy shots. The Applicant is required to certify that the Applicant has discussed stopping allergy shots with his or her physician and that the physician agrees that the allergy shots can be stopped without unreasonable risk of substantial harm to the Applicant's health.

• Asthma Evaluation Form

(a) Estimated number of Applicants/physicians: 500/500.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 75 minutes/30 minutes.

(d) Estimated total reporting burden: 625 hours/250 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: When an Applicant reports on the Health History Form symptoms of moderate persistent or severe persistent asthma in the past two years, he or she is provided an Asthma Evaluation Form for the treating physician to complete. The determination of whether the reported symptoms indicate moderate persistent or severe persistent asthma is based on recognized classifications of asthma severity. The Asthma Evaluation Form asks for the physician to document the Applicant's condition of asthma, including any asthma symptoms, triggers, treatments, or limitations or restrictions due to the condition, as well as to certify that the Applicant can safely serve 27 months overseas. This form is used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to meet the essential eligibility requirements for a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems. This form is also used to determine the type of accommodation that may be needed, such as placement of the Applicant within reasonable proximity to a hospital in case treatment is needed for a severe asthma attack.

• Diabetes Diagnosis Form

(a) Estimated number of Applicants/physicians: 36/36.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 75 minutes/30 minutes.

(d) Estimated total reporting burden: 45 hours/18 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: When an Applicant reports the condition of diabetes Type 1 on the Health History Form, the Applicant is provided a Diabetes Diagnosis Form for the treating physician to complete. In certain cases, the Applicant may also be asked to have the treating physician complete a Diabetes Diagnosis Form if the Applicant reports the condition of diabetes Type 2 on the Health History Form. The Diabetes Diagnosis Form asks the physician to document the diabetes diagnosis, etiology, possible complications, and treatment, as well as to certify that the Applicant can safely serve 27 months overseas. This form is used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to meet the essential eligibility requirements for a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems. This form is also used to determine the type of accommodation that may be needed, such as placement of an Applicant who requires the use of insulin in order to ensure that adequate insulin storage facilities are available at the Applicant's site.

• Disease Diagnosis Form

(a) Estimated number of Applicants/physicians: 400/400.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 75 minutes/30 minutes.

(d) Estimated total reporting burden: 500 hours/200 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: When an Applicant reports on the Health History Form a medical condition of significant severity (other than one covered by another form), he or she may be provided a Disease Diagnosis Form for the treating physician to complete. The Disease Diagnosis Form may also be provided to an Applicant whose responses on the Health History Form indicate that the Applicant may have an unstable medical condition that requires ongoing treatment. The Disease Diagnosis Form asks the physician to document the diagnosis, etiology, possible complications and treatment, as well as to certify that the Applicant can safely serve 27 months overseas. This form is used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to meet the essential eligibility requirements for a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems. This form is also used to determine the type of accommodation that may be needed, such as placement of an Applicant to take account of the Applicant's medical condition (e.g., avoidance of high altitudes or proximity to a hospital).

• Low Body Mass Index Evaluation Form

(a) Estimated number of Applicants/physicians: 50/50.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 105 minutes/60 minutes.

(d) Estimated total reporting burden: 87.5 hours/50 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: When an Applicant reports a height and weight on the Health History Form consistent with a body mass index (BMI) that is below 17 for women and 18 for men, the Applicant will be provided a Low Body Mass Index Evaluation Form for a physician to complete. The Low Body Mass Index Evaluation Form asks the physician to indicate whether the Applicant's low BMI is indicative of any condition which could be exacerbated during Peace Corps service. This form is used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to meet the essential eligibility requirements for a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems. Based on the information on the completed form, the Peace Corps may determine that further medical assessments are required.

• Mental Health Treatment Summary Form

(a) Estimated number of Applicants/physicians: 150/150.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 105 minutes/60 minutes.

(d) Estimated total reporting burden: 262.5 hours/150 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: The Mental Health Treatment Form is used when an Applicant reports on the Health History Form a history of certain serious mental health conditions, such as bipolar disorder, schizophrenia, mental health hospitalization, attempted suicide or cutting, or treatments or medications related to these conditions. In these cases, an Applicant is provided a Mental Health Treatment Summary Form for a licensed mental health counselor, psychiatrist or psychologist to complete. The Mental Health Treatment Summary Form asks the counselor, psychiatrist or psychologist to document the dates and frequency of therapy sessions, clinical diagnoses, symptoms, course of treatment, psychotropic medications, mental health history, level of functioning, prognosis, risk of exacerbation or recurrence while overseas, recommendations for follow up and any concerns that would prevent the Applicant from completing 27 months of service without undue disruption. This form is used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to meet the essential eligibility requirements for a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems. This form is also used to determine the type of accommodation that may be needed, such as placement of the Applicant in a country with appropriate mental health support.

• Eating Disorder Treatment Summary Form

(a) Estimated number of Applicants/physicians: 232/232.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 105 minutes/60 minutes.

(d) Estimated total reporting burden: 406 hours/232 hours.

(e) Estimated annual cost to respondents: Indeterminate.

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

• Mental Health Current Evaluation Form

(a) Estimated number of Applicants/professional: 439/439.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 265 minutes/180 minutes.

(d) Estimated total reporting burden: 1,939 hours/1,317 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: The Mental Health Current Evaluation Form is used when an Applicant reports a mental health condition in the Health History Form and it is determined that a current mental health evaluation is needed. A current mental health evaluation might be needed if information on the condition is outdated or previous reports on the condition do not provide enough information to adequately assess the current status of the condition. In these cases, the Applicant will be provided a Mental Health Current Evaluation Form for a licensed mental health counselor, psychiatrist or psychologist to complete over one to three evaluation sessions. The Mental Health Current Evaluation Form asks the mental health professional to document the clinical diagnoses, presenting symptoms, risk of recurrence in a stressful overseas environment, coping strategies, evaluation of overall functioning, psychotropic medications, current psychological tests administered, recommendations for follow up, and any concerns that would prevent the Applicant from completing 27 months of service without undue disruption due to the diagnosis. This form is used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to meet the essential eligibility requirements for a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems. This form is also used to determine the type of accommodation that may be needed, such as placement of the Applicant in a country with appropriate mental health support.

• Alcohol/Substance Abuse Evaluation Form

(a) Estimated number of Applicants/specialist: 100/100.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 165 minutes/60 minutes.

(d) Estimated total reporting burden: 275 hours/100 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: The Alcohol/Substance Abuse Current Evaluation Form is used when an Applicant reports in the Health History Form a history of substance abuse (i.e., alcohol or drug related problems such as blackouts, daily or heavy drinking patterns or the misuse of illegal or prescription drugs) and that this substance abuse affects the Applicant's daily living or that the Applicant has ongoing symptoms of substance abuse. In these cases, the Applicant is provided an Alcohol/Substance Abuse Current Evaluation Form for a substance abuse specialist to complete. The Alcohol/Substance Abuse Current Evaluation Form asks the substance abuse specialist to document the history of alcohol/substance abuse, dates and frequency of any therapy sessions, which alcohol/substance abuse assessment tools were administered, mental health diagnoses, psychotropic medications, self-harm behavior, current clinical assessment of alcohol/substance use, clinical observations, risk of recurrence in a stressful overseas environment, recommendations for follow up, and any concerns that would prevent the Applicant from completing 27 months of service without undue disruption due to the diagnosis. This form is used as the basis for an individualized determination as to whether the Applicant will, with reasonable accommodation, be able to meet the essential eligibility requirements for a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems. This form is also used to determine the type of accommodation that may be needed, such as placement of the Applicant in a country with appropriate sobriety support or counseling support.

• Mammogram Form

(a) Estimated number of Applicants: 224.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 105 minutes.

(d) Estimated total reporting burden: 392 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: The Mammogram Form is used with all female Applicants who will be 50 years of age or older, who have received invitations to serve as Volunteers. The purpose of the form is to provide the Peace Corps with results of the Applicant's latest mammogram and to record the wishes of the Applicant regarding routine mammogram screening during service. The Peace Corps uses the information in the Mammogram Form to determine if the Applicant currently has breast cancer and to ascertain whether the Applicant wishes to receive routine mammogram screening while in service. A female Applicant who wishes to receive routine mammogram screening during service will be limited to being placed in a country with mammogram screening capabilities. If the Applicant waives routine mammogram screening during service, the Applicant's physician also completes this form in order to confirm that the physician has reviewed the Applicant's risk factor assessment and discussed the results with the Applicant and concurs that foregoing screening mammography represents an acceptable risk.

• Pap Screening Form

(a) Estimated number of Applicants/physicians: 2,695/2,695.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 25 minutes/15 minutes.

(d) Estimated total reporting burden: 1,123 hours/674 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: The Pap Screening Form is used with all female Applicants who have received invitations to serve as Volunteers. They are required to obtain a Pap examination within four months prior to their departure. This form assists the Peace Corps in determining whether a female Applicant with mildly abnormal Pap results will need to be placed in a country with appropriate Pap follow-up capabilities.

• Colon Cancer Screening Form

(a) Estimated number of Applicants: 354.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 60 minutes—165 minutes.

(d) Estimated total reporting burden: 354 hours—973.5 hours.

(e) Estimated annual cost to respondents: Indeterminate.

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

• ECG Form

(a) Estimated number of Applicants/physicians: 354/354.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 25 minutes/15 minutes.

(d) Estimated total reporting burden: 147.5 hours/88.5 hours.

(e) Estimated annual cost to respondents: Indeterminate.

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

• Reactive Tuberculin Test Evaluation Form

(a) Estimated number of Applicants/physicians: 352/352.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 75-105 minutes/30 minutes.

(d) Estimated total reporting burden: 440-616 hours/176 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: The Reactive Tuberculin Test Evaluation Form is used when an Applicant, who has received an invitation to serve as Volunteer, reports a history of reactivity to tuberculosis skin testing or a history of BCG vaccination in the Health History Form or if a reactivity is discovered as part of the Applicant's physical examination. In these cases, the Applicant is provided a Reactive Tuberculin Test Evaluation Form for the treating physician to complete. The treating physician is asked to document the type and date of a current TB test, TB test history, diagnostic tests if indicated, treatment history, risk assessment for developing active TB, current TB symptoms, and recommendations for further evaluation and treatment. In the case of a positive result on the TB test, a chest x-ray is also required, along with treatment for latent TB.

• Insulin Dependent Supplemental Documentation Form

(a) Estimated number of Applicants/physicians: 8/8.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 70 minutes/60 minutes.

(d) Estimated total reporting burden: 9.3 hours/8 hours.

(e) Estimated annual cost to respondents: Indeterminate.

General Description of Collection: The Insulin Dependent Supplemental Documentation Form is used with Applicants, who have received invitations to serve as Volunteers, and who have reported on the Health History Form that they have insulin dependent diabetes. In these cases, the Applicant is provided an Insulin Dependent Supplemental Documentation Form for the treating physician to complete. The Insulin Dependent Supplemental Documentation Form asks the treating physician to document that he or she has discussed with the Applicant medication (insulin) management, including whether an insulin pump is required, as well as the care and maintenance of all required diabetes related monitors and equipment. This form assists the Peace Corps in determining whether the Applicant will be in need of insulin storage while in service and, if so, will assist the Peace Corps in determining an appropriate placement for the Applicant.

• Prescription for Eyeglasses Form

(a) Estimated number of Applicants/physicians: 2,432/2,432.

(b) Frequency of response: One time.

(c) Estimated average burden per response: 105 minutes/15 minutes.

(d) Estimated total reporting burden: 4,256 hours/608 hours.

(e) Estimated annual cost to respondents: Indeterminate.

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

Request for Comment: Peace Corps invites comments on whether the proposed collections of information are necessary for proper performance of the functions of the Peace Corps, including whether the information will have practical use; the accuracy of the agency's estimate of the burden of the proposed collection of information, including the validity of the information to be collected; and, ways to minimize the burden of the collection of information on those who are to respond, including through the use of automated collection techniques, when appropriate, and other forms of information technology.

This notice is issued in Washington, DC, on November 21, 2013.

Denora Miller,

FOIA/Privacy Act Officer, Management.