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

Forms and Documents

Document Name	Status
Form DS-6570 Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Form and Instruction	Modified
ESCAPE Form Legal Authorities.docx Supplementary Document	2016-11-28
Final - 30 Day ESCAPE Form Supporting Statement.docx Supporting Statement A	2016-11-28

IC Document Collections

IC ID	Document Title	Status
221440	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0224	ICR Reference No: 201611-1405-004
Status: Historical Active	Previous ICR Reference No: 201605-1405-002
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/26/2017
	Date Received in OIRA: 11/28/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved	01/31/2017
Responses	200	0	200
Time Burden (Hours)	100	0	100
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose for soliciting this information is to make appropriate medical clearance decisions that better assess potential bidders that are capable of the unique, potentially challenging and life-threatening conditions at Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) posts and are capable of performing certain emergency safety functions.

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Authorizing Statute(s): US Code: 22 USC 3901 Name of Law: the Foreign Service Act of 1980
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 62547	09/09/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 83922	11/22/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)	DS-6570	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Posts PRE-DEPLOYMENT PHYSICAL EXAM ACKNOWLEDGEMENT FORM

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	200	200	0	0	0	0
Annual Time Burden (Hours)	100	100	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/28/2016

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