SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT
SUBMISSION
OMB # 1405-0131, DS-3057
Why is this collection necessary and what are the legal statutes that allow this?
Under the authority of the Foreign Service Act of 1980 (22 U.S.C. 3901) and the Basic Authorities Act of 1956 (22 U.S.C. 2651), the Secretary has the ability to establish a medical program. As specified in 16 FAM 211, the medical program provides medical examinations for applicants for employment and also medical examinations as necessary for members of the Foreign Service and employees of the Department and their eligible family members . The Medical Clearance Program ensures that all members of the Foreign Service, other Department employees, other Agency employees through the ICASS program, and their family members have appropriate medical facilities abroad for any underlying medical conditions.
What business purpose is the information gathered going to be used for?
The information requested on the DS-3057 is required for professional medical staff of the Bureau of Medical Services to make decisions on the type of medical clearance an individual and family members are assigned. This medical clearance, in turn, is used by the Foreign Service to determine posts abroad where the Foreign Service member and family may serve. The information collected is not directly released to any other Federal, State, or local agency. During security investigations certain aspects of the information collected may be released to the investigating agency once a certified need is determined and medical privacy statutes and regulations do not otherwise protect the information.
Is this collection able to be completed electronically (e.g. through a website or application)?
The DS-3057 is available throughout the Department of State via the e-Forms electronic forms application. The form is 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.
Does this collection duplicate any other collection of information?
The information collected is generally not duplicative of other collections, with the exception of basic identification and contact information. Addresses, agency, type of employment, and other information can routinely change during the periods between the medical clearance update. Family members in particular may change status, type of employment, and other information that is collected. Medical information required will routinely change from medical clearance update to update. Use of the DS-3057 Medical Clearance Update form allows comparison of salient health conditions from one clearance update to another without necessitating a physical examination.
Describe any impacts on small business.
This collection of information does not impact small businesses.
What are consequences if this collection is not done?
Not collecting the required information on the DS-3057 will result in assignments of Foreign Service Officers, Federal employees, and their families to posts abroad that do not have adequate medical facilities to treat their underlying medical conditions. It will result in increased costs for the medical program; will not effectively utilize the dollars allocated to the Medical Program; and will increase costs of medical liability claims, disability claims, and other medical/legal costs associated with the Medical Program. The current requirement for a medical clearance is between post assignments or every three years, whichever is longer. This frequency serves the Department well and obtains the required information at the time that it is needed and not before.
Are there any special collection circumstances?
There are no circumstances that would require the information to be collected in the manner described in the instructions for the supporting statement.
Document publication (or intent to publish) a request for public comments in the Federal Register
The Department will publish a notice in the Federal Register soliciting public comments for a period of 60 days.
Are payments or gifts given to the respondents?
The Department does not make any type or form of payment to the respondent for this collection.
Describe assurances of privacy/confidentiality
Medical records and other medical information identified to a particular individual are protected under the Privacy Act of 1974. 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. This information is covered by System of Records Notice STATE-24, Medical Records.
Are any questions of a sensitive nature asked?
This form requires a Foreign Service Officer, Federal employee, contractor or family member to provide information regarding mental health status, past mental health treatment, and chronic medical conditions. 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. The form also requires a discussion regarding any special educational needs that a dependent child may have. Existence of such needs might preclude assignment to some overseas posts.
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 8,782 DS-3057 responses annually, with an estimation of 30 minutes for respondents to complete the form. The annual hour time burden for respondents to complete the form is 4,391 annual hours (8,782 responses x 30 minutes / 60).
The average mean hourly wage for civilians across all occupations is $29.76.1 The Department multiplied the wage rate by a factor of two to account for the cost of fringe benefits and overhead costs.2 The annual cost burden to complete the form is $261,352.32 ($59.52 [cost per response] x 4,391 [annual hours]).
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-3057 is $15.65 (total average hourly cost per employee 93.99 x [10 / 60]). The annual cost to the federal government to process DS-3057 forms is $137,438.30 (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 reinstatement of a discontinued collection. The changes to the document include correcting typographical errors; formatting the font for clarity; rewording some questions and adding some new questions. The word patient has been changed to examinee through out the form. We are no longer using the word clearance and have replaced it with the word review in the title. The gender section has been expanded to include gender identity, and pronouns. Agency and employment type has been expended to include more options. Additional question was added about specialist you may see for a medical/mental health condition.
The 8,782 respondents represent approximately a 51% decrease from the previous Paperwork Reduction Act submission which included federal employees as respondents. This year’s figure only includes members of the public such as contractors and eligible family members.
16. Specify if the data gathered by this collection will be published.
The information collected will not be published or routinely tabulated. The only tabulation that is required is the total number of clearances issued.
17. If applicable, explain the reason(s) for seeking approval to not display the OMB expiration date.
The Bureau of Medical Services will display the expiration date on the form.
18. 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 in the collection process nor in the use of the information collected.
1 Source: (2022) 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 |
| File Title | SUPPORTING STATEMENT FOR |
| Author | USDOS |
| File Modified | 0000-00-00 |
| File Created | 2023-12-19 |