SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION
OMB Number 1405-
0068
Medical History and
Examination for Foreign Service
DS-1843 and DS-1622
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 information needed to determine whether a candidate for a Foreign Service appointment is able to obtain the medical clearance required 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. Revisions to the forms are needed to clarify that the information collection is consistent with applicable authorities, including 42 U.S.C. § 2000ff, Title II, and 29 C.F.R. Part 1635.
The information collected in Form DS-1843 is used to determine if a candidate can obtain the medical clearance that is required for appointment to the Foreign Service. Also, the information collected in Form DS-1843 and Form DS-1622 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 when assigned abroad.
Presently, the forms are available on the State Department internet site, via the myData application, which is a new system that will provide electronic format that will utilize the ServiceNow platform. The demographic sections are electronically “fillable” but each individual must provide a paper copy to his or her personal health care provider, and once completed, the forms are scanned and submitted via facsimile or e-mail. The form is then scanned as an image into the DOS Electronic Medical Record (EMR). At this time, there is no electronic submission capability that automatically integrates this information collection into the EMR or our Medical Clearances software application. The Bureau of Medical Services is actively investigating and soliciting product information from commercial EMR products in conjunction with Acquisitions processes. Estimated completion date is mid-2018.
The information is generally not duplicated with other collection instruments, with the exception of basic identification and contact information. The medical information collected can routinely change from one clearance exam to the next, as can addresses, agency, type of employment, status of family members, and other information.
This collection of information does not impact small businesses or other small entities.
This information collection is required for the determination of medical clearance classification for applicants to the Foreign Service. Additionally, the information 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 is shorter, and this frequency allows for the issuance of appropriate medical clearances. Not collecting the required information will result in assignments of Foreign Service Officers and their family members abroad that do not have adequate medical facilities and medical resources to treat their underlying medical conditions.
There are no circumstances that would require the information to be collected in the manner described in the instructions for the supporting statement.
A 60-day notice was published in the Federal Register on March 27, 2017 (82 FR 15266) and elicited no public comments.
The Department does not make any type or form of payment to the respondent.
Medical records and other medical information associated with a particular individual are governed under the Privacy Act of 1974, 5 U.S.C. § 552a. The Bureau of Medical Services is authorized to collect this health information pursuant to section 904 of the Foreign Service Act, 22 U.S.C. § 4084.
These forms requires a Foreign Service Officer or applicant, or family member to provide information regarding chronic medical conditions, mental health status, and past mental health treatment. Although not routinely discussed, except with a person’s health care provider, these questions are necessary to gauge the individual and family members’ ability to be assigned to hardship posts, or posts where medical resources are scarce. These forms also might include information regarding special educational needs that a dependent child may have.
The Department of State Bureau of Medical Services estimates the hour burden to be 7,814 hours per year.
The
number of respondents per year is approximately 7,814. This number is
based on data collection of all DS-1843 and DS-1622 forms processed
by medical records in FY 2015 for applicants, employees, and eligible
family members. These forms are required upon entry to the Foreign
Service, and intermittently through 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.
Number of Respondents: 7,814 per year.
Form DS-1843 = 5,489
Form DS-1622 = 2,325
Aggregate = 7,814
Frequency of Response: On entrance to the Foreign Service and on occasion afterwards.
The hour burden cost was estimated to be $ 516,427.26 based on the hour burden of 7814 hours x $66.09 hour. This was determined using the U.S. Department of Labor, Bureau of Labor Statistics website (www.bls.gov), the average mean hourly wage for a nurse practitioner is $47.21/hr., multiplied by 1.4 for a weighted hourly wage of $66.09.
There are no costs to respondents.
Total cost to the Federal Government is $126,039.82.
The printing cost, ($0.05 per page) for 31,256 pages (7,814 x 4 pages per response) is $1,562.80.
The scanning cost to process the form into our Electronic Medical Record System is estimated at $3.17 per form for a total of $24,770.38 per year. The cost of processing the form is estimated at $12.76 per form multiplied by 7,814 forms or $99,706.64 per year.
Adding all costs together for the printing, scanning and processing, and labor, the total cost is $126,039.82.
This is a renewal of a previously-approved collection. Decrease in program burden due to use of simplified medical clearance update form DS-3057, once initial medical exam completed. The improved data collection of the Office of Medical Clearances is also reflected in the actual numbers of respondents annually versus an estimated number used previously. As for forms DS-1622 and DS-1843, the changes were done to improve demographic collection, purpose of collection, and assignment information. Changes also include: instructions on submission were updated and revised; medical history questions were revised to include common cancer screening testing; mental health, substance abuse and educational questions revised; laboratory testing burden reduced; some laboratory and cancer screening testing made optional, at discretion of examiner and not required for medical clearance determination; and Privacy Act Notice updated and Genetic Information Nondiscrimination Act (GINA) guidance amended to include notice to individual completing form.
The Department will not publish the results of this collection.
The Department will display the expiration date for OMB approval of the information collection.
There are no exceptions to the certification statement.
This collection does not employ statistical methods in the collection process nor in the use of the information collected.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | "%username%" |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |