[Federal Register Volume 85, Number 165 (Tuesday, August 25, 2020)]
[Notices]
[Pages 52382-52386]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-18575]


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PEACE CORPS


Information Collection Request; Submission for OMB Review

AGENCY: Peace Corps.

ACTION: 60-Day notice and request for comments.

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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.

DATES: Submit comments on or before October 26, 2020.

ADDRESSES: Comments should be addressed to Virginia Burke, FOIA/Privacy 
Act Officer. Virginia Burke can

[[Page 52383]]

be contacted by email at [email protected]. Email comments must be 
made in text and not in attachments.

FOR FURTHER INFORMATION CONTACT: Virginia Burke at the 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 (PC-262-2)

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(a) Estimated number of Applicants/         800/800.
 physicians.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  75 minutes/30 minutes.
(d) Estimated total reporting burden......  1,000 hours/400 hours.
(e) Estimated annual cost to respondents..  $23,240/$38,740.
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    General Description of Collection: When an Applicant reports on the 
Health History Form (PC-1789) 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 (PC-262-3)

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(a) Estimated number of Applicants/         37/37.
 physicians.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  75 minutes/30 minutes.
(d) Estimated total reporting burden......  46 hours/19 hours.
(e) Estimated annual cost to respondents..  $1,069/$1,840.15.
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    General Description of Collection: When an Applicant reports the 
condition of diabetes Type 1 on the Health History Form (PC-1789), the 
Applicant will be provided a Diabetes Diagnosis Form for the treating 
physician to complete. In certain cases, the Applicant may also be 
asked to have the treating physician complete a Diabetes Diagnosis Form 
if the Applicant reports the condition of diabetes Type 2 on the Health 
History Form. The Diabetes Diagnosis Form asks the physician to 
document the diabetes diagnosis, etiology, possible complications, and 
treatment. This form will be used as the basis for an individualized 
determination as to whether the Applicant will, with reasonable 
accommodation, be able to perform the essential functions of a Peace 
Corps Volunteer assignment and complete a tour of service without 
unreasonable disruption due to health problems. This form will also be 
used to determine the type of accommodation that may be needed, such as 
placement of an Applicant who requires the use of insulin in order to 
ensure that adequate insulin storage facilities are available at the 
Applicant's site.
 Transfer of Care--Request for Information Form (PC-262-13)

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(a) Estimated number of Applicants/         3,100/3,100.
 physicians.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  75 minutes/30 minutes.
(d) Estimated total reporting burden......  3,875 hours/1,550 hours.
(e) Estimated annual cost to respondents..  $90,055/$150,117.5.
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    General Description of Collection: When an Applicant reports on the 
Health History Form (PC-1789) 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 
(PC-262-14)

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(a) Estimated number of Applicants/         2,500/2,500.
 professional.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  105 minutes/60 minutes.
(d) Estimated total reporting burden......  4,375 hours/2,500 hours.
(e) Estimated annual cost to respondents..  $101,675/$24,212.5.
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    General Description of Collection: The Mental Health Current 
Evaluation and Treatment Form will be used when an Applicant reports on 
the Health History Form (PC-1789) 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

[[Page 52384]]

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 (PC-262-15)

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(a) Estimated number of Applicants/         90/90.
 professional.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  90 minutes/45 minutes.
(d) Estimated total reporting burden......  135/67.5 hours.
(e) Estimated annual cost to respondents..  $3,137.40/$6,537.37.
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    General Description of Collection: When an Applicant reports on the 
Health History Form (PC-1789) a functional ability limitation, he or 
she will then 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 (PC-262-8)

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(a) Estimated number of Applicants/         110/110.
 physicians.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  105 minutes/60 minutes.
(d) Estimated total reporting burden......  193 hours/110 hours.
(e) Estimated annual cost to respondents..  $4,485.32/$10,653.5.
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    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 (PC-1789). 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 (PC-262-6)

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(a) Estimated number of Applicants/          90/90.
 specialist.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  165 minutes/60 minutes.
(d) Estimated total reporting burden......  248 hours/90 hours.
(e) Estimated annual cost to respondents..  $5,763.52/$8,716.5.
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    General Description of Collection: The Substance-Related and 
Addictive Disorders Current Evaluation Form is used when an Applicant 
reports in the Health History Form (PC-1789) 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 (PC-355-2)

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(a) Estimated number of Applicants/         190.
 physicians.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  105 minutes.
(d) Estimated total reporting burden......  333.
(e) Estimated annual cost to respondents..  $7,738.92.
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    General Description of Collection: The Mammogram Waiver 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. It is anticipated that this part of 
the form will be completed when the Applicant goes to a physician for 
the required physical examination.
 Cervical Cancer Screening Form (PC-262-11)

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(a) Estimated number of Applicants........  4,600/4,600.
(b) Frequency of response.................  one time.

[[Page 52385]]

 
(c) Estimated average burden per response.  40 minutes/30 minutes.
(d) Estimated total reporting burden......  3,067 hours/2,300 hours.
(e) Estimated annual cost to respondents..  $71,277.08/$22,275.5.
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    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

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(a) Estimated number of Applicants........  450.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  60-165 minutes.
(d) Estimated total reporting burden......  450-1,238 hours.
(e) Estimated annual cost to respondents..  $10,458.
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    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. It is anticipated that this part of the form will be 
completed when the Applicant goes to a physician for the required 
physical examination.
 Electrocardiogram (ECG/EKG) Form (PC-262-7)

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(a) Estimated number of Applicants/         476/467.
 physicians.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  25 minutes/15 minutes.
(d) Estimated total reporting burden......  198 hours/119 hours.
(e) Estimated annual cost to respondents..  $4,601.52/$11,525.15.
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    General Description of Collection: The Electrocardiogram (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 (PC-262-12)

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(a) Estimated number of Applicants/         109/109.
 physicians.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  75-105 minutes/30 minutes.
(d) Estimated total reporting burden......  136-191 hours/55 hours.
(e) Estimated annual cost to respondents..  $3,160.64-$4,438.84/
                                             $5,326.75.
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    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 (PC-1789) 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 (PC-262-10)

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(a) Estimated number of Applicants/         9/9.
 physicians.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  70 minutes/60 minutes.
(d) Estimated total reporting burden......  11 hours/9 hours.
(e) Estimated annual cost to respondents..  $255.64/$871.65.
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    General Description of Collection: The Insulin Dependent 
Supplemental Documentation Form is used with Applicants who have 
reported on the Health History Form (PC-1789) 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 (PC-OMS-116)

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(a) Estimated number of Applicants/         3,750/3,750.
 physicians.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  60 minutes/15 minutes.
(d) Estimated total reporting burden......  3,750 hours/938 hours.
(e) Estimated annual cost to respondents..  $8,7150/$90,845.30.
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    General Description of Collection: The Prescription for Eyeglasses 
Form is used with Applicants who have reported on the Health History 
Form (PC-1789) 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

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(a) Estimated number of Applicants/         5,100.
 physicians.
(b) Frequency of response.................  one time.
(c) Estimated average burden per response.  60 minutes.
(d) Estimated total reporting burden......  5,100 hours.
(e) Estimated annual cost to respondents..  $11,8524.
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    General Description of Collection: The Required Peace Corps 
Immunizations

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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. It is anticipated that this part of the form will be 
completed when the Applicant goes to a physician for the required 
physical examination.
    Request for Comment: The 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 August 19, 2020.
Virginia Burke,
FOIA/Privacy Act Specialist, Management.
[FR Doc. 2020-18575 Filed 8-24-20; 8:45 am]
BILLING CODE 6051-01-P