SSA_3206NEW_OFXX (formerly SF78)

Supporting Statement for Paperwork Reduction Act Submission

Optional Form XX (OF-XX) - Certificate of Medical Examination
Revision of Standard Form 78 (SF-78)

Under the provisions of the Paperwork Reduction Act of 1995 (Public Law 104-13, May 22, 1995), the Office of Personnel Management (OPM) is submitting to the Office of Management and Budget (OMB) a request for the use of the Optional Form (OF-XX), Certificate of Medical Examination, a revision of Standard Form 78 (SF-78), which will be used to collect medical information about individuals who are incumbents of positions which require physical fitness/agility testing and medical examinations, or who have been selected for such a position contingent upon meeting physical fitness/agility testing and medical examinations as a condition of their employment. This information is needed to ensure fair and consistent treatment of employees and job applicants, to adjudicate passover of a preference eligible, and to adjudicate claims of discrimination under the Americans with Disabilities Act (ADA).

A. Justification for Optional Form XX (OF-XX).

1. Veterans’ preference is established by the Veterans Preference Act of 1944, as amended, and is now codified in various provisions of title 5, United States Code (U.S.C.). By law, veterans who are disabled or who served on active duty in the Armed Forces during certain specific time periods or in military campaigns are entitled to preference over others in hiring from competitive lists of eligibles. Specifically, 5 U.S.C. 3312, 3318, 3504; and 5 CFR part 339 - Medical Qualification Determinations and 5 CFR 351.702(d) – Qualifications for Assignment; speak to ensuring that applicants are treated fairly and not discriminated against because of a medical or physical condition that would not affect their ability to perform the duties of the position.
The medical passover of a preference eligible, or rejection of a veteran with a service-connected disability rated at 30 percent or more, are raised by Federal agencies or the U.S. Postal Service for adjudication by OPM.

The new OPM OF-XX Form may be used for all positions which require a medical examination. This form replaces the existing SF-78, Certificate of Medical Examination, which was revised by the Civil Service Commission in October 1969. Revision and replacement is necessary because the SF-78 is no longer accurate. Revisions include making the form optional for agencies rather than required; to delete outdated references, such as the Federal Personnel Manual; and to incorporate changes required by 29 CFR 1630.13, which relates to prohibited medical inquiries and examinations related to the Equal Employment Opportunity provisions of the ADA.

2. In formulating this adjudication decision, the OPM and agency examining offices will use the information from the OF-XX, including supporting documentation, to determine whether an applicant for a Federal job is physically able to perform the duties of the position. Without this information, officials would not know how to adjudicate a passover request. The submission of documents alone, without the OF-XX, would not satisfy this need.

3. Electronic alternatives to the OF-XX would not be cost-effective because of the amount of information that is actually collected. The supporting documentation that must be submitted with the OF-XX provides most of the information agencies use to adjudicate veterans’ preference. The information may come from the military, the Department of Veterans Affairs, the courts, hospitals, or medical practitioners, as appropriate. The form will be available on OPM’s website in PDF fillable format.

4. There are no duplicative efforts in this process. If the supporting documentation submitted with the OF-XX is inadequate, the examining office must contact the agency requesting that OPM render a passover determination to attain all relevant data required to complete the review and render a final determination concerning the physical ability of the employee to perform the duties of the position with undue risk to the health and safety of themselves or others.

5. The collection of information does not affect small businesses or other small entities.

6. Veterans’ preference is a factor considered in Federal hiring. Federal agencies and the USPS are unable to proceed in the selection of a non-preference eligible to a position until OPM has rendered a determination relative to an agency adjudication request regarding a medical passover of a preference eligible, or rejection of a veteran with a service-connected disability rated at
30 percent or more.

7. There are no special reporting or recordkeeping requirements that increase the burden on the applicant.

8. In the 60-Day Notice, we proposed to submit to OMB a request for clearance of an updated information collection instrument and invited comments on the OF-XX.

The notice was reported in FR Vol. 71, No. 244, on December 20, 2006. At that time, we invited public comment on the need for information, its practical utility, the accuracy of OPM’s burden estimate, and ways to minimize that reporting burden. OPM received comments from three Federal agencies, which have been addressed in revising the form.

These comments included questions as to: 1) why we were changing the SF-78; 2) a request for the Certificate of Medical Examination to be added to the OPM website and made electronically fillable, and requested additional space for description of functions employee will be performing; 3) a request for OPM to add room for clinician comments on positive findings; and 4) a request for OPM to reformat Part A to allow added room for names, to create separate and distinct parts, to change “glasses” to “corrective lenses”, to add check boxes to areas where an examiner may document his or her interpretation of test results, and to more clearly delineate vision and hearing boxes by moving instructions inside of the boxes where results are to be recorded.

9. No payment or gift is made to respondents.

10. The Privacy Act Statement printed on the form identifies limitations on disclosure.
The Privacy System of Records covering this information is OPM Government 5: Recruiting, Examining, and Placement Records.

11. The OF-XX, Certificate of Medical Examination, collects personal and sensitive medical information about an applicant which is necessary for OPM to render a medical adjudication relative to an applicant’s ability to safely and efficiently perform the duties of the position without undue risk or harm to the individual, to the safety of others, or to the vulnerability to business operating and information systems. The information is collected, maintained and protected by OPM as required under the Privacy Act.

12. OPM estimates approximately 45,000 forms will be completed each year. Each form requires from two to three hours to complete with an annual estimated burden of 135,000 hours.

There is no cost to the respondent to complete this form.

13. There is no cost to respondents for the collection of information or its recordkeeping.

14. OPM estimates annual usage of the OF-XX form is 45,000. Cost can be calculated by processing the total estimated forms (45,000) at a rate of $2.66 per form for a total of $119,700 plus 25% overhead ($7,482.58), resulting in a total cost of $127,182.58 to the Government.

15. The reporting burden is 135,000 hours. Providing the OF-XX in an easily accessible online version, both fillable and printable, will aid agencies in hiring greater numbers of disabled veterans into the Federal Government. An increasing use of the OF-XX, and the reporting burden each successive year, can be attributable to additional hiring of disabled veterans.

16. Frequency of recordkeeping or recording is not applicable. Information is not published.

17. A request is being made not to publish an expiration date. It is time-consuming and
cost-prohibitive to reissue this form only to change the OMB expiration date.

18. Agency contact would not be applicable for this purpose.

B. Collection of Information Employing Statistical Methods.

Not applicable.

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