Federal Register / Vol. 77, No. 13 / Friday, January 20, 2012 / Notices 3013 

filing a document in this manner are 

responsible for serving the document on 

all other participants. Filing is 

considered complete by first-class 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 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. 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. 

If a person other than Mr. Francis 

Guilbeau requests a hearing, that person 

shall set forth with particularity the 

manner in which his interest is 

adversely affected by this Order and 

shall address the criteria set forth in 10 

CFR 2.309(d). 

If a hearing is requested by Mr. 

Guilbeau or any other person whose 

interest is adversely affected, the 

Commission will issue an order 

designating the time and place of any 

hearings. 

If a hearing is held, the issue to be 

considered at such hearing shall be 

whether this Order should be sustained. 

In the absence of any request for hearing 

or ADR, or written approval of an 

extension of time in which to request a 

hearing, the effective date of this Order 

(the date that the provisions specified in 

Section IV above become final and 

effective) shall be 30 days from the 

issuance date of this Order without 

further order or proceedings. If an 

extension of time for requesting a 

hearing has been approved, the effective 

date of this Order shall be when the 

extension expires if a hearing request 

has not been received. If a hearing or 

ADR is requested, the effective date of 

this Order shall be determined in 

accordance with the hearing or ADR 

process. 

Dated this 5th day of January 2012. 

For the Nuclear Regulatory Commission. 

Roy P. Zimmerman, 

Director, Office of Enforcement. 

[FR Doc. 2012–1060 Filed 1–19–12; 8:45 am] 

BILLING CODE 7590–01–P 

PEACE CORPS 

Submission for OMB Review; Request 

for Comments 

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 March 20, 2012. 

ADDRESSES: Comments should be 

addressed to Denora Miller, FOIA 

Officer, Peace Corps, 1111 20th Street 

NW., Washington, DC 20526. Denora 

Miller can be contacted by telephone at 

(202) 692–1236 or email at 

pcfr@peacecorps.gov. Email comments 

must be made in text and not in 

attachments. 

FOR FURTHER INFORMATION CONTACT: 

Denora Miller at Peace Corps address 

above. 

SUPPLEMENTARY INFORMATION: The Peace 

Corps Act states that ‘‘[t]he President 

may enroll in the Peace Corps for 

service abroad qualified citizens and 

nationals of the United States (referred 

to in this Act as ‘‘volunteers’’). The 

terms and conditions of the enrollment 

* * * of volunteers shall be exclusively 

those set forth in this Act and those 

consistent therewith which the 

President may prescribe * * *’’ 22 

U.S.C. 2504(a). Eligibility requirements 

for the Peace Corps have been 

prescribed in 22 CFR part 305. Among 

those eligibility requirements is one 

relating to medical status. An Applicant 

‘‘must, with reasonable accommodation, 

have the physical and mental capacity 

required of a Volunteer to perform the 

essential functions of the Peace Corps 

Volunteer assignment for which he or 

she is otherwise eligible and be able to 

complete an agreed upon tour of service, 

ordinarily two years, without undue 

disruption due to health problems.’’ 22 

CFR 305.2(c). All applicants for service 

must undergo a physical examination 

and a dental evaluation prior to 

Volunteer service to determine if they 

meet this medical status eligibility 

requirement. In addition, under 22 

U.S.C. 2504(e), the Peace Corps provides 

medical care to Volunteers during their 

service and the information collected 

will also be used in connection with 

medical care and treatment during 

Peace Corps service for applicants who 

become Volunteers. Finally, the 

information collected may serve as a 

point of reference for any potential 

future Volunteer worker’s compensation 

claims. 

Volunteers serve in 67 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 current process requires almost 

all Applicants to undergo a costly and 

time consuming full medical evaluation. 

Under the current process, it sometimes 

happens that after an Applicant has 

spent large amounts of time and money, 

the Peace Corps finds that the Applicant 

is not medically qualified to serve. In 

2012, the Peace Corps will change the 

current process in order to reduce the 

time and expense of Applicants and to 

ensure that only those who accept an 

invitation to serve undergo a complete 

medical evaluation. However, 

Applicants who have certain 

particularly difficult to accommodate 

conditions will be evaluated early in the 

process. This will reduce the time and 

expense for those Applicants who 

would, even with reasonable 

accommodation, not be likely to be able 

to perform the essential functions of a 

Peace Corps Volunteer and complete a 

tour of service without undue 

disruption due to health problems. 

Under the new system, the Applicant 

will begin the medical part of the 

application process by completing a 

comprehensive health history form 

called the ‘‘Health History Form’’. After 

completion of the Health History Form 

and after passing preliminary nonVerDate Mar<15>2010 14:12 Jan 19, 2012 Jkt 226001 PO 00000 Frm 00067 Fmt 4703 Sfmt 4703 E:\FR\FM\20JAN1.SGM 20JAN1

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health-related assessments, the 

Applicant will be ‘‘nominated’’ to a 

program. This nomination does not 

guarantee an invitation to serve, but it 

does hold a place so the Applicant may 

proceed with the process. After a review 

by the Peace Corps pre-service medical 

staff of the Health History Form and any 

supplemental forms that the Applicant 

is required to submit following 

nomination, the Applicant may be 

medically pre-cleared. An Applicant 

who is medically pre-cleared and who 

accepts an invitation to serve as a Peace 

Corps Volunteer undergoes a final 

medical clearance. Final medical 

clearance is on the basis of a complete 

physical examination, as documented in 

a Report of Physical Examination. 

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 results of the physical 

examination and the information 

contained in the specific evaluation 

forms covered by this Supporting 

Statement will be used to make an 

individualized determination as to 

whether an Applicant for Volunteer 

service will, with reasonable 

accommodation, be able to perform the 

essential functions of a Peace Corps 

Volunteer and complete a tour of service 

without undue disruption due to health 

problems. 

If, based on the Applicant’s responses 

on the Health History Form, additional 

information is required in order to make 

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 undue 

disruption due to health problems, then 

one or more of the forms listed below 

may be sent to the Applicant. 

Method: The Peace Corps will 

introduce these forms electronically as 

part of a larger business process 

improvement project. Applicants will 

gain access to the forms via a secure 

online portal. As described below, in 

most instances, 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. The Peace Corps 

anticipates that most Applicants will 

submit the forms electronically and that 

only those with no electronic access 

will submit a paper version. 

Title: Individual Specific Medical 

Evaluation Forms (16). 

OMB Control Number: 0420-pending. 

Type of Review: New. 

Respondents: Individuals/Physicians. 

Respondents’ Obligation to Reply: 

Required for Volunteer service. 

Burden to the Public: 

• Allergy Treatment Form 

(a) Estimated number of Applicants/ 

physicians—100/100 

(b) Frequency of response—one time 

(c) Estimated average burden per 

response—20 minutes/10 minutes 

(d) Estimated total reporting burden— 

33.3 hours/16.7 hours 

(e) Estimated annual cost to 

respondents—Indeterminate 

General description of collection: 

When an Applicant reports that he or 

she is currently receiving allergy shot 

treatments, Peace Corps provides the 

Applicant with an Allergy Treatment 

Form for his or her treating physician to 

complete. The Peace Corps is not able 

to arrange for Volunteers to receive 

allergy shots during their Peace Corps 

service. Peace Corps Volunteers 

generally serve in areas that are isolated 

and have limited access to Westerntrained providers and health care 

systems. The Applicant completes the 

form after discussing with his or her 

physician whether the Applicant will be 

able to live overseas for 27 months of 

Peace Corps service without receiving 

allergy shots. The Applicant is required 

to certify that the Applicant has 

discussed stopping allergy shots with 

his or her physician and that the 

physician agrees that the allergy shots 

can be stopped without unreasonable 

risk of substantial harm to the 

Applicant’s health. 

• Asthma Evaluation Form 

(a) Estimated number of Applicants/ 

physicians—500/500 

(b) Frequency of response—one time 

(c) Estimated average burden per 

response—75 minutes/30 minutes 

(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 

will be 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 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 undue 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—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 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, as well as 

to certify that the Applicant can safely 

serve 27 months overseas. 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 undue 

disruption due to health problems. This 

form will also be used to determine the 

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 


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(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 

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 undue 

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 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 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 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 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 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 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 undue 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. 

• 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 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 undue 

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 undue 

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. 

• 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 


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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 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 undue 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. 

• 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 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 undue 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 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 


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1 15 U.S.C. 78s(b)(1). 

2 17 CFR 240.19b–4. 

(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 January 13, 2012. 

Garry W. Stanberry, 

Acting Associate Director, Management. 

[FR Doc. 2012–1040 Filed 1–19–12; 8:45 am] 

BILLING CODE 6051–01–P 

SECURITIES AND EXCHANGE 

COMMISSION 

[Release No. 34–66148; File No. SR–C2– 

2012–001] 

Self-Regulatory Organizations; C2 

Options Exchange, Incorporated; 

Notice of Filing and Immediate 

Effectiveness of a Proposed Rule 

Change To Amend the Fees Schedule 

January 13, 2012. 

Pursuant to Section 19(b)(1) of the 

Securities Exchange Act of 1934 (the 

‘‘Act’’),1 and Rule 19b–4 thereunder,2

notice is hereby given that on January 5, 

2012, the C2 Options Exchange, 

Incorporated (the ‘‘Exchange’’ or ‘‘C2’’) 

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 Exchange. 

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 Substance of 

the Proposed Rule Change 

The Exchange proposes to amend the 

Fees Schedule. The text of the proposed 

rule change is available on the 

Exchange’s Web site (http:// 

www.cboe.org/legal), at the Exchange’s 

Office of the Secretary, and at the 

Commission. 

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 the 

Statutory Basis for, the Proposed Rule 

Change 

1. Purpose 

The Exchange proposes to amend its 

Fees Schedule to state that CMI and FIX 

connectivity charges will be charged on 

a per-Login ID basis. Firms may access 

C2 via either a CMI Client Application 


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