SupportingStatement-USMS Medical Forms-2016 Renewal

Supporting Statement

1105-0099

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

It is the policy of the USMS to ensure a law enforcement work force that is medically able to safely perform the required job functions. Operational employees (as opposed to administrative employees) are required to meet medical standards and physical requirements and are classified as either qualified or unqualified based on review of periodic medical examination results.

The authority for collection of the information on these forms is as follows:

• USM-522A Physician Evaluation Report for USMS Operational Employees

Solicitation of this information is authorized by 5 U.S.C. 552a, regarding records maintained on individuals; 5 U.S.C. 3301, regarding determination as to an individual's fitness for employment with regard to age, health, character, knowledge and ability; and 5 U.S.C. 3312, regarding waiver of physical qualifications for preference eligibles. 5 CFR § 339 defines the circumstances when medical documentation may be required, and examinations and evaluations are conducted to determine the nature of a medical condition that may affect safe and efficient performance.

• USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only

Solicitation of this information is authorized by 5 U.S.C. 552a, regarding records maintained on individuals; 5 U.S.C. 3301, regarding determination as to an individual's fitness for employment with regard to age, health, character, knowledge and ability; and 5 U.S.C. 3312, regarding waiver of physical qualifications for preference eligibles. 5 CFR § 339 defines the circumstances when medical documentation may be required, and examinations and evaluations are conducted to determine the nature of a medical condition that may affect safe and efficient performance.

• USM-600 Physical Requirements of USMS District Security Officers

The authority for collection of this information is 28 U.S.C. 561, as well as 5 U.S.C. 3301 which allows for the collection of information to ascertain the fitness of applicants as to age, health, character, knowledge, and ability for the employment sought. The USMS requires the information requested in this form to evaluate an applicant/incumbent’s qualifications to perform the duties of a District Security Officer with respect to the supervising, processing and transporting of federal prisoners.

• CSO-012 Request to Reevaluate Court Security Officer’s Medical Qualification

The authority for collection of this information is set forth in 28 U.S.C. 561; 28 U.S.C. 566; and 5 U.S.C. 3301.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

• USM-522A Physician Evaluation Report for USMS Operational Employees

  • How Used: This form is to be used by operational law enforcement employees who are restricted from full performance of their duties for longer than 80 consecutive hours due to injury or illness; or by prospective operational law enforcement employees who are impacted by medical issues prior to completing the Training Academy.

  • Used By Whom: The employee’s personal physician. It is reviewed by the Reviewing Medical Officer at the Federal Occupational Health Law Enforcement Medical Program and USMS Office of Employee Health Programs for the final medical determination as to fitness for duty.

• For What Purpose: The primary use of this information will be to determine the nature of a medical or physical condition that may affect safe and efficient performance of the work described in the employee’s position description.

• USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only

  • How Used: This form is to be used by operational law enforcement employees who are temporarily restricted from performing all of their duties due to pregnancy. In accordance with USMS Policy Directive 3.5, Fitness for Duty Medical Examination Program, after a physician has confirmed the pregnancy, or no later than the completion of the first trimester of pregnancy (the end of the 13th week), the operational employee is responsible for securing a completed Form USM-522P, or equivalent, from her physician.

  • Used By Whom: The employee’s personal physician. It is reviewed by the Reviewing Medical Officer at the Federal Occupational Health Law Enforcement Medical Program and USMS Office of Employee Health Programs for the final medical determination as to fitness for duty.

• For What Purpose: The primary use of this information will be to determine the nature of a medical or physical condition that may affect safe and efficient performance of the work described in the employee’s position description.

• USM-600 Physical Requirements of USMS District Security Officers

  • How Used: Annual completion of Form USM-600 is required to ensure that all applicant and incumbent District Security Officers (DSOs) meet the medical standards as outlined in the Statement of Work and are medically qualified to perform all District Security Officer duties.

• Used By Whom: The applicant’s personal physician and Contracting Officer (CO). Once the applicant’s personal physician has certified the applicant is fit for duty, it is read by the Contracting Officer (CO) in the District and included in the DSO certification file for the applicant.

• For What Purpose: This form is necessary to ensure that USMS District Security Officers are medically able to safely perform the required job functions. USMS has a similar form (Form USM-522, Physical Examination Report for USMS Operational Employees) which is completed by USMS designated physicians for operational (non-administrative) USMS employees, but it does not apply to DSOs because they are independent contractors.

• CSO-012 Request to Reevaluate Court Security Officer’s Medical Qualification

• How Used: Use of this form is required when a Court Security Officer (CSO) is returning to perform security services after recovering from an injury, extended illness, and/or outpatient or inpatient surgery, including such procedures as LASIK. A Court Security Officer may not resume security services until the USMS Office of Court Services has provided written approval for the individual to resume performing under the applicable contract.

• Used By Whom: This form is completed by the CSO’s attending physician. The physician returns the evaluation to the contracting company, and if the determination is that the CSO may return to work, Form CSO-012 is then signed off on by the contracting company and forwarded to the USMS for final review by the designated USMS Medical Reviewing Official.

• For What Purpose: The primary use of this information will be to determine the nature of a medical or physical condition that may affect safe and efficient performance of the work described in the contractor’s position description. USMS has a similar form (Form USM-522A, Physician Evaluation Report for USMS Operational Employees) which is completed by USMS designated physicians for operational (non-administrative) USMS employees, but it does not apply to CSOs because they are contractors with a separate set of requirements which determine fitness for duty.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

The forms may be completed electronically but must be printed and signed by hand before being submitted.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

Existing medical forms such as OF-178 Certificate of Medical Examination do not meet U.S. Marshals Service (USMS) needs because they do not ask law enforcement position-specific questions that allow proper assessment of fitness for duty.

5. If the collection of information impacts small businesses or other small entities (Item 5 of OMB Form 83-I), describe any methods used to minimize burden.

This collection of information does not impact small businesses.

6. Describe the consequence to Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

USM-522A and USM-522P: Without the information collected by physical examination or focused testing, we would be out of compliance with established regulations and unable to track exposures on the job as mandated by OSHA (surveillance criteria of exposures - 29 CFR 1910). In addition, need to ensure applicant and employee fitness to perform the essential job duties of the position applied for or assigned to ensure mission readiness and success. Administrators of the program need the information collected by these examinations and tests to evaluate how the applicant or employee can or cannot perform the essential functions at the time of the evaluation and then make a duty determination. All decisions made must be legally defensible.

USM-600: Without the information collected by the physical examination of the individual, the USMS would not be able to ensure that all applicant and incumbent District Security Officers (DSOs) are medically qualified to perform the duties which they would be assigned. USMS must verify that applicant and incumbent DSOs are able to perform the essential job duties of the position applied for or assigned in order to ensure mission readiness and success.

CSO-012: The medical condition of the CSO workforce is critical to verify that all Court Security Officers (DSOs) are medically qualified to ensure the overall safety of the Judiciary.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

* requiring respondents to report information to the agency more often than quarterly;

* requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

* requiring respondents to submit more than an original and two copies of any document;

* requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records, for more than three years;

* in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

* requiring the use of a statistical data classification that has not been reviewed and approved by OMB;

* that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

* requiring respondents to submit proprietary trade secrets, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

The Department anticipates no circumstances under which a request for the assumption of concurrent Federal criminal jurisdiction would be subject to any of the following conditions:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records, for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of a statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secrets, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years - even if the collection of information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

The Department solicited comments on the information collection in FR Volume 81, Number 90, page 28887 (May 10, 2016) and FR Volume 81, Number 147, page 50550 (August 1, 2016). The comment period for the proposed rule has closed and the Department received no comments on the information collection.

9. Explain any decision to provide any payment or gift to respondents, other than reenumeration of contractors or grantees.

The Department has made no decision to provide any payment or gift to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

There is no assurance of confidentiality.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

The Department is not requesting such information.

12. Provide estimates of the hour burden of the collection of information. The statement should:

* Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

* If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB Form 83-I.

* Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 13.

The Department estimates the number of minutes necessary to submit a request on USM-522A Physician Evaluation Report for USMS Operational Employees to be approximately 20 per responder, with approximately 208 possible responders. This estimate is based on the average number of responders utilizing this form in FY13, FY14 and FY15. Each responder utilizes this form at least two times. In order to calculate the public burden, the Department multiplied 20 minutes by 416 (208 responders times 2 responses each), the sum divided by 60 (the number of minutes in an hour), which equals 139 total hours of annual burden hours.

The Department estimates the number of minutes necessary to submit a request on the USM-522P Physician Evaluation Report for USMS Operational Employees – Pregnancy Only to be approximately 15 per responder, with approximately 7 possible responders.  This estimate is based on the average number of responders utilizing this form in FY13 and FY15. Each responder utilizes this form at least two times. In order to calculate the public burden, the Department multiplied 15 minutes by 14 (7 responders times 2 responses each) and divided 60 (the number of minutes in an hour), which equals 4 total annual burden hours.

The Department estimates the number of minutes necessary to submit a request on USM-600 Physical Requirements of USMS District Security Officers to be approximately 20 per responder, with approximately 500 possible responders. In order to calculate the public burden, the Department multiplied 20 by 500 and divided by 60 (the number of minutes in an hour), which equals 166.67 total annual burden hours.

The Department estimates the number of minutes necessary to submit a request on CSO-012 Request to Reevaluate Court Security Officer’s Medical Qualification to be approximately 30 per responder, with approximately 300 possible responders. In order to calculate the public burden, the Department multiplied 30 by 300 and divided by 60 (the number of minutes in an hour), which equals 150 total annual burden hours.

13. Provide an estimate for the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

* The cost estimate should be split into two components: (a) a total capital and start-up cost component (annualized over its expected useful life) and (b) a total operation and maintenance and purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

* If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collections services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

* Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.

There is no cost associated with submitting these requests.

14. Provide estimates of annualized costs to the Federal government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies may also aggregate cost estimates from Items 12, 13, and 14 in a single table.

USM-522A and USM-522P:

Item	Cost
Staff time averaging 2 hours per form to review and process records for 300 USM-522A forms per year at the average wage of  $55.00/hour	$33,000
Staff time averaging 1 hour per form to review and process records for 12 USM-522P forms per year at the average wage of  $55.00/hour	$660
Physician review by Federal Occupational Health for 300 USM-522A forms per year at an average of $79.00 per form.	$23,700
Physician review by Federal Occupational Health for 12 USM-522P forms per year at an average of $79.00 per form.	$948
Total Estimate	$58,308

USM-600:

Item	Cost
Staff time of 2.5 hours to review forms, create files and maintain files for 500 medical files/year at the average wage of $37.37/hour	$46,713
Total Estimate	$46,713

CSO-012:

Item	Cost
Staff time averaging 2 hours per form to review and process records for 300 CSO-012 forms per year at the average wage of $40.00/hour	$24,000
Physician review by Federal Occupational Health for 300 CSO-012 forms per year at an average of $79.00 per form.	$23,700
Total Estimate	$47,700

Methods to estimating costs:

• Estimates for the future year’s data collection.

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.

N/A

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

N/A

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

N/A

18. Explain each exception to the certification statement identified in Item 19, "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I.

N/A