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


=======================================================================
-----------------------------------------------------------------------

PEACE CORPS


Information Collection Request Submission for OMB Review

AGENCY: Peace Corps.

ACTION: 60-day notice and request for comments.

-----------------------------------------------------------------------

SUMMARY: The Peace Corps will be submitting the following information 
collection request to the Office of Management and Budget (OMB) for 
review and approval. The purpose of this notice is to allow 60 days for 
public comment in the Federal Register preceding submission to OMB. We 
are conducting this process in accordance with the Paperwork Reduction 
Act of 1995 (44 U.S.C. Chapter 35).

DATES: Submit comments on or before January 17, 2017.

ADDRESSES: Comments should be addressed to Denora Miller, FOIA/Privacy 
Act Officer. Denora Miller can be contacted by telephone at 202-692-
1236 or email at [email protected]. Email comments must be made in 
text and not in attachments.

FOR FURTHER INFORMATION CONTACT: Denora Miller at Peace Corps address 
above.

SUPPLEMENTARY INFORMATION: 
    Title: Individual Specific Medical Evaluation Forms (15).
    OMB Control Number: 0420-0550.
    Type of Request: Revision/New.
    Affected Public: Individuals/Physicians.
    Respondents Obligation to Reply: Voluntary.
    Respondents: Potential and current volunteers.
    Burden to the Public:

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

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

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

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

[[Page 81180]]

of an Applicant who requires the use of insulin in order to ensure that 
adequate insulin storage facilities are available at the Applicant's 
site.

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

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

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

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

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

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

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

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

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

    General Description of Collection: The Alcohol/Substance Abuse 
Current

[[Page 81181]]

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

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

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

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

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

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

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

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

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

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

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

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

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

[[Page 81182]]

including whether an insulin pump is required, as well as the care and 
maintenance of all required diabetes related monitors and equipment. 
This form assists the Peace Corps in determining whether the Applicant 
will be in need of insulin storage while in service and, if so, will 
assist the Peace Corps in determining an appropriate placement for the 
Applicant.

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

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

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

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

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