Hiring Center Medical Records Privacy Release (Form 3400)

Forms and Documents

Document Name	Status
Form 3400 Medical Records Privacy Act Release Form Form and Instruction	New
SS 1651-0NEW CBP Hiring Center Medical Records Privacy Act Release Form.docx Supporting Statement A	2022-08-22
5 CFR 339.305 (up to date as of 8-18-2022).pdf Supplementary Document	2022-08-22
30FRN 1651-0NEW Medical Records Privact Act Release Form.pdf Supplementary Document	2022-08-22
5 CFR 339.301 (up to date as of 8-18-2022).pdf Supplementary Document	2022-08-22
SORN-OPM-GOV5.pdf Supplementary Document	2022-08-16
DHS-CBP-PIA-032a.pdf Supplementary Document	2022-08-16
60-day FRN 1651-0NEW.pdf Supplementary Document	2022-08-04

IC Document Collections

IC ID	Document Title	Status
255165	Medical Records Privacy Act Release Form Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202208-1651-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DHS/USCBP	Agency Tracking No:
Title: Hiring Center Medical Records Privacy Release (Form 3400)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/23/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	208	0
Time Burden (Hours)	52	0
Cost Burden (Dollars)	0	0

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Abstract: In accordance with 5 CFR 339.301, Customs and Border Protection (CBP) performs pre-employment medical evaluations on all candidates tentatively selected to fill positions that include a medical requirement, such as the CBP Officer and Border Patrol Agent positions. During that evaluation process, CBP collects medically relevant information about the candidate from: the candidate, CBP’s contracted medical providers, and/or the candidate’s personal medical and mental health providers. In accordance with 5 CFR 339.305, CBP makes all medical documentation and records of examination available to the candidates. Candidates can request copies of their pre-employment medical examination results and supporting documentation/records by email or letter. Due to the sensitive nature of the information being released, CBP requires that candidates complete and sign a privacy release authorization form in order to receive a copy of their medical documents. CBP will only share medical information directly with the candidate, or with a third party when authorized to do so in writing by the candidate. No specific information is needed to request copies of candidates’ medical documents in writing. When completing the release form, candidates must provide the following information: Full name, partial Social Security Number (SSN#), Date of Birth, Current Address, Email Address, Phone Number; as well as specifying the type of medical records to be released (hearing test results, vision test results, etc.). This information is used by CBP as confirmation that the agency has the candidate’s signed authorization to provide medically related records about the candidate. A copy of that signed authorization and the records released are retained within the candidate’s pre-employment file.

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Authorizing Statute(s): None

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:
	87 FR 14902	03/16/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 51440	08/22/2022
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
Medical Records Privacy Act Release Form	3400	Hiring Center Medical Records Privacy Act Release Form

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ICR Summary of Burden

	Total Request	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	208	0	0	208	0	0
Annual Time Burden (Hours)	52	0	0	52	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new collection of information.

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Annual Cost to Federal Government: $30,780

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: 08/23/2022

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