Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0224 can be found here:

Documents and Forms

Document Name Document Type
Form DS-6570 Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Form and Instruction
DS-6570 Employee Self-Certification and Ability to Perform in Em DS-6570 (DRAFT 5-04-2016).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-6570	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Posts PRE-DEPLOYMENT PHYSICAL EXAM ACKNOWLEDGEMENT FORM	DS-6570 (DRAFT 5-04-2016).pdf		No		Fillable Fileable

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.