SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION
Insert
Collection name as shown in OMB records
OMB
Number 1405 - 0224
Why is this collection necessary and what are the legal statutes that allow this?
The DS-6570 (Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Posts, Pre-Deployment Physical Exam Acknowledgement Form) is used to identify individuals with health concerns that may be a hazard to themselves or their colleagues while deployed at high threat Diplomatic Missions. This form is required by 16 STATE 62384, paragraph 3 and confirmed in 13 FAM 325, which implements the Foreign Service Act of 1980 (22 U.S.C. 4084).
What business purpose is the information gathered going to be used for?
The DS-6570 is completed by an individual and their medical provider to identify if that individual has health concerns that may represent a safety hazard for the individual or others at an ESCAPE post. Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) posts are diplomatic missions overseas that are in extremely high threat areas with the potential for combat. Current ESCAPE missions are, Afghanistan, Iraq, Libya Somalia, Syria, Yemen and Peshawar in Pakistan. The questions on the form identify health risks that might predict an emergency medical situation for that patient or indicate that an individual may not be able to self-evacuate in the event of conflict.
Is this collection able to be completed electronically (e.g. through a website or application)?
The DS-6570 form is posted on the MED Medical Clearances internet website as a PDF form. The form is to be completed, signed, and dated by provider and patient. The form is then sent to MED Medical Records by email in a PDF format or as a FAX transmission.
Does this collection duplicate any other collection of information?
It does not duplicate any previously collected information. The information gathered is specific to a very small group of people deploying as civilians to conflict areas under the auspices of the U.S. Government. The questions asked are not typically asked on routine medical exams.
Describe any impacts on small business.
There is no impact to small businesses.
What are consequences if this collection is not done?
The DS-6570 is designed to promote the safety of individuals and their colleagues posted to Diplomatic Missions in very high threat posts. These evacuations require special air flights out of a conflict zone, risking the lives of those required for the transport and potentially delaying life-saving care for the individual. MED Clearances may limit the deployment of an individual that self-identifies a health concern using this form.
Are there any special collection circumstances?
There are no special collection circumstances. The distribution of this form is limited to the individuals who may be deployed to ESCAPE posts who also have access to the Department of State Medical Program.
Document publication (or intent to publish) a request for public comments in the Federal Register
No comments were received
Are payments or gifts given to the respondents?
The Department does not make any type or form of payment to the respondent.
Describe assurances of privacy/confidentiality
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.
Are any questions of a sensitive nature asked?
This is a medical document and asks personal medical questions. Questions are limited to identifying health issues that could lead to a sudden medical emergency or a health issue that would inhibit the individual’s ability to self-evacuate in a conflict situation.
Describe the hour time burden and the hour cost burden on the respondent needed to complete this collection.
The Office of Medical Clearances receives approximately 1900 DS-6570 responses annually, taking approximately 30 minutes for respondents to complete the form and an average of 10 minutes to review per nursing consultant. The annual hour time burden for respondents to complete the form is 1266 hours (1900 responses x 40 minutes / 60).
The mean hourly wage for federal employees across all occupations is $36.93, and the mean hourly wage for civilians across all occupations is $24.98.1 The average mean wage rate for DS-6570 respondents is $30.96 ($36.93 + $24.98 / 2). The Department multiplied the wage rate by a factor of two to account for the cost of fringe benefits and overhead costs.2 The cost per response for respondents is $30.96 ($30.96[2] x 30 / 60). The annual hourly cost burden to complete the form is $58,824.00 (cost per response x number of responses).
Describe the monetary burden to respondents (out of pocket costs) needed to complete this collection.
There is no monetary burden placed on respondents.
Describe the cost incurred by the Federal Government to complete this collection.
The estimated average wage rate for the office is a General Schedule 12, Step 5 in the Washington-Baltimore-Arlington, DC-MD-VA-WV-PA area, which amounts to an hourly base rate of $48.78.3 The average hourly cost of benefits for federal employees, across all levels of education, is $28.54 (adjusted from $26.50 in FY2015 dollars).4 The U.S. Department of State’s estimated hourly overhead expense is 16.67 per hour.5 The Office of Medical Clearances’ total average cost per employee, factoring wage, benefits, and overhead, is $93.99 per hour.
The cost burden to process a DS-6570 is $15.08 (total average hourly cost per employee x [10 / 60]). The annual cost to the federal government to process DS-6570 forms is $28,652.00 (the cost burden to process the response x total annual responses).
Explain any changes/adjustments to this collection since the previous submission
This is a renewal of a previously approved collection. The changes to the document include: correcting typographical errors; formatting the font for clarity; updating the questions.
Specify if the data gathered by this collection will be published.
No data will be gathered for publication.
If applicable, explain the reason(s) for seeking approval to not display the OMB expiration date.
The Department will display the OMB expiration date.
Explain any exceptions to the OMB certification statement below.
The Department is not seeking exceptions to the certification statement.
This collection does not employ statistical methods.
1 Source: (2018) Bureau of Labor Statistics: https://www.bls.gov/oes/current/999101.htm#00-0000 (federal); https://www.bls.gov/oes/current/oes_nat.htm#00-0000 (civilian)
2 Source: (2016) U.S. Department of Health and Human Services, “Guidelines for Regulatory Impact Analysis”, https://aspe.hhs.gov/system/files/pdf/242926/HHS_RIAGuidance.pdf.
3 Source: (2022) Office of Personnel Management, “Salary Table 2022” - Pay & Leave : Salaries & Wages - OPM.gov
4 Source: (2017) Congressional Budget Office, “Comparing the Compensation of Federal and Private-Sector Employees, 2011 to 2015” - https://www.cbo.gov/publication/52637. The FY2015 average hourly cost of benefits for federal employees was adjusted using the Bureau of Labor Statistics Consumer Price Index inflation calculator.
5 Source: (2016) U.S. Department of Health and Human Services, “Guidelines for Regulatory Impact Analysis”, https://aspe.hhs.gov/system/files/pdf/242926/HHS_RIAGuidance.pdf. On page 30, HHS states, “As an interim default, while HHS conducts more research, analysts should assume overhead costs (including benefits) are equal to 100 percent of pretax wages….” To isolate the overhead rate, the Department subtracted the benefits rate of 63 percent from the recommended rate of 100 percent.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Suchernick, Kevin |
| File Modified | 0000-00-00 |
| File Created | 2022-09-28 |