Application for Civil Surgeon Designation

Forms and Documents

Document Name	Status
Form I-910 Application for Civil Surgeon Designation Form	Modified
I-910-005-30FRN-85FR26488_05042020.pdf Supplementary Document	2020-05-06
I-910-005-REV-SPTSTMT.docx Supporting Statement A	2020-05-06
I910-005-FRM-TOC-Revision-30 Day-04202020.docx Supplementary Document	2020-05-01
I910-005-INS-TOC-Revision-30 Day-04202020.docx Supplementary Document	2020-05-01
I-910-005-60FRM-85FR5979-2020-01975.pdf Supplementary Document	2020-05-01
privacy-pia-uscis-067-civilsurgeon-june1,2017.pdf Supplementary Document	2018-04-10
privacy-pia-064-uscis-myuscis-dec14,2016.pdf Supplementary Document	2020-05-01
SORN 007 Benefits Info Sys 2016 10 19.pdf Supplementary Document	2018-04-10
PTA, USCIS - Application for Civil Surgeon Designation Form I-910, 20200122, PRIV Final.pdf Supplementary Document	2020-05-01
Reference_Citations[1].doc Supplementary Document	2015-10-27

IC Document Collections

IC ID	Document Title	Status
192797	Application for Civil Surgeon Designation Form	Modified

ICR Details

OMB Control No: 1615-0114	ICR Reference No: 202005-1615-001
Status: Historical Active	Previous ICR Reference No: 201804-1615-001
Agency/Subagency: DHS/USCIS	Agency Tracking No: I-910
Title: Application for Civil Surgeon Designation
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/23/2020
	Date Received in OIRA: 05/06/2020
Terms of Clearance: Approved for two years only due to partial GPEA compliance.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2022	36 Months From Approved	07/31/2020
Responses	470	0	538
Time Burden (Hours)	940	0	1,076
Cost Burden (Dollars)	24,205	0	26,459

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Abstract: This information collection is required to determine whether a physician meets the statutory and regulatory requirement for civil surgeon designation.

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Authorizing Statute(s): US Code: 8 USC 1182 Name of Law: U.S. Code
  

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:
	85 FR 5979	02/03/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 26488	05/04/2020
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Application for Civil Surgeon Designation	I-910	Application for Civil Surgeon Designation

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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	470	538	0	0	-68	0
Annual Time Burden (Hours)	940	1,076	0	0	-136	0
Annual Cost Burden (Dollars)	24,205	26,459	0	0	-2,254	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: There is a decrease of 136 hours in the estimated annual hour burden, which resulted from a decrease in the estimated number of respondents to this collection of information. Although the form for this information collection has been modified to collect additional address and interpreter information from applicants and the instructions have been revised for greater clarity, the modifications did not necessitate an increase in the estimated hour burden per response.

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Annual Cost to Federal Government: $368,950

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

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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: 05/06/2020

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