1405-0068 Supporting Statement 2-20-2015

SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION

OMB Number 1405-0068

Medical History and Examination for Foreign Service

A. JUSTIFICATION

1. Pursuant to 22 U.S.C. § 4084, the Secretary of State has the authority to establish a Medical Program. This information collection provides to the U.S. Department of State’s Office of Medical Services the material needed to determine whether a candidate for a Foreign Service appointment and their children, if applicable, are able to obtain the medical clearance that is a requirement for that appointment, and to determine the appropriate medical clearances for other individuals who participate in the Medical Program. The information is requested pursuant to the Foreign Service Act of 1980, as amended, in particular 22 U.S.C. §§ 4084, 3901, and 3984. (Note: For purposes of the Paperwork Reduction Act, only non-employees are considered “respondents” regarding this information collection.)

2. The use of DS-1843 is required for individuals age 12 and older while DS-1622 is required for children 11 years and under. The information collected in these forms is used to determine if candidates or their children can obtain the medical clearance which is an essential part of the selection process for the appointment to the Foreign Service. Also, the information collected is used to provide and to update medical clearances between overseas assignments for individuals who participate in the Medical Program, as well as to provide these individuals with appropriate medical care.

3. The Department is preparing a new electronic medical record system, in which these documents will eventually be incorporated, but the system is not operational at this time. Presently, each individual provides his or her personal health care provider with a copy of the forms, which, once completed, are scanned and submitted via facsimile or e-mail. It is anticipated a system will be in place by August, 2015.

4. The information collected is not duplicative. The medical information collected can routinely change with each medical clearance update, as can the address, agency, type of employment, and other information.

5. This collection of information does not impact small businesses or other small entities.

6. This information collection is needed for the determination as to whether Foreign Service candidates are qualified for appointment, because without that determination offers of employment cannot be extended. If the FS candidate is appointed the information requested in the DS-1622 and the DS-1843 is needed in order to issue appropriate in-service medical clearances. In most cases, medical clearance updates are required between post assignments or every three years, whichever shorter, and this frequency allows for the issuance of appropriate medical clearances.

7. There are no circumstances that would require the information to be collected in the manner described.

8. An emergency 60-day notice was published in the Federal Register on 16 August, 2013 in Vol. 78, No. 159. No public comments were received.

9. The Department does not provide a payment or gift to the respondents.

10. The information will be kept private to the extent permitted by law.

11. These forms, which include Privacy Act Notices, collect medical information that is needed to determine the appropriate medical clearance for Federal Service personnel or their children.

12. The Department of State Office of Medical Services estimates the hour burden of 23,245 hours per year. This is the exact number of Medical Clearance Examination forms submitted to the Office of Medical Clearances in FY2012, up from 4,000 in 2004. These forms are required upon entry into the Foreign Service and intermittently throughout each Foreign Service employee’s career. The annual burden was estimated based upon the number of respondents and an estimate of one hour to gather the information, transcribe the information, print and sign the form, and send it to Medical Clearances. The annual cost to the respondents, based on appropriate wage rate categories is $781,032. This number was determined using the U.S. Department of Labor, Bureau of Labor Statistics website (www.bls.gov). The average mean hourly civilian earnings on July 2013 was $23.98/hr, rounded to $24.00 and multiplied by 1.4 for a weighted hourly wage of $33.60.

13. There are no costs to respondents. The Department of State authorizes payment for all costs of medical examinations (unless an insurance company has paid for the examination).

14. Total cost to the Federal Government is $373,081.40. The printing cost ($0.03 per page) for 92,980 pages (23245 responses x four pages per response) is $2,789.40. The scanning cost to process the form into our Electronic Medical Record System is estimated at $3.17 per form for a total of $73,686.00 per year. The cost of processing the form is estimated at $12.76 per form multiplied by 23,245 forms or $296,606.00 per year. Adding all costs together, the total cost of this form to the Federal Government is $373,081.40.

15. The numbers of respondents has increased since 2011 when the Office of Medical Clearances processed approximately 8,000 clearances. Of the 30,000 medical clearances processed in the past consecutive 12 months, 23,245 respondents used DS-1843 and DS-1622. This represents a program adjustment. Additionally, revisions to the Forms are needed to clarify that the information collection is consistent with applicable authorities, including the Genetic Information Nondiscrimination Act of 2008 (GINA) (42 U.S.C. § 2000ff, Title II, and 29 C.F.R. Part 1635). In particular, the Forms’ questions concerning family medical history and genetic tests (which are not used for appointment purposes) are being removed, and the Forms are being amended to include GINA’s “safe harbor” language, instructing those who are completing the Forms that they should not provide genetic information, as defined by GINA.

Two edits are being made to DS-1843. For Page 2 Item 42, “Pregnancy History (number of times)” the categories of “miscarriage,” “premature births,” “abortions,” and “living children.” Were removed because they were confusing clients and the information did not impact medical clearance adjudications. For Page 4 Item 3, “Serology Hep B Surface Antigen, instructions “(If known, HBsAB pos. or has had immunizations, do not repeat)” were deleted because the instructions were confusing to respondents.

16. Responses will not be published.

17. The Department is not seeking approval to remove the expiration date.

18. Not applicable

B. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS

This collection does not employ statistical methods.