Document Headings

                    Document headings vary by document type but may contain                    the following:                  
                -                       the agency or agencies that issued and signed a document                    
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###### 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 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:

Comments must be submitted on or before April 26, 2012.

# ADDRESSES:

                        Interested persons are invited to submit comments regarding this proposal. Comments should refer to the proposal by name/or OMB approval number and should be sent via email to:                         *oira_submission@omb.eop.gov*                         or fax to: 202-395-3086. Attention: Desk Officer for Peace Corps.                    

# FOR FURTHER INFORMATION CONTACT:

                        Denora Miller, FOIA Officer, Peace Corps, 1111 20th Street NW., Washington, DC 20526, (202) 692-1236, or email at                         *pcfr@peacecorps.gov.*                         Copies of available documents submitted to OMB may be obtained from Denora Miller at address listed 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                           ( print page 18274)                        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 non-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 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 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.                          ( print page 18275)    

*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.

(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                           ( print page 18276)                        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 out-dated 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 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                           ( print page 18277)                        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.                

Dated: This notice is issued in Washington, DC on March 22, 2012.

Garry W. Stanberry,

Acting Associate Director, Management.

[FR Doc. 2012-7339 Filed 3-26-12; 8:45 am]

BILLING CODE 6051-01-P