USAID Contractor Employee Physical Examination Form

Forms and Documents

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Collection	Type	Status	Form
848	USAID Contractor Employee Physical Examination Form	Form	Migrated

ICR Details

OMB Control No: 0412-0536	ICR Reference No: 200010-0412-001
Status: Historical Active	Previous ICR Reference No: 199706-0412-001
Agency/Subagency: AID	Agency Tracking No:
Title: USAID Contractor Employee Physical Examination Form
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/05/2001
	Date Received in OIRA: 10/06/2000
Terms of Clearance: The agency is instructed to conduct a review of this information collection to clarify the need for the two page form collected from the individual and provided to the doctor and to ensure that future submissions accurately reflect this portion of the collection. The agency must also review both forms to ensure that all information is necessary, including the question on the race of the respondent. Finally, the agency must review its Privacy Act compliance and ensure that applicants are fully informed of their rights under the Privacy Act and of all routine uses for the doctor's information. This approval includes as burden the $249,100 reported by the agency as a financial cost to the respondents for the medical exames. Future submissions must include nonlabor financial cost to the respondents.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2002	08/31/2002
Responses	1,460	0	0
Time Burden (Hours)	8,760	0	0
Cost Burden (Dollars)	249,000	0	0

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Abstract: USAID needs to use standardized medical examinations for contractors before their assignment to developing countries. By evaluating the employee's medical status in order to complete the examination form, the employee's physician will be better informed as to the possible health risks the employee will face and can better determine the employee's suitability for the assignment. The physican's determination may protect the employee and benefits USAID and the contractor by screening out persons with medical conditions for which adequate medical care is not available.

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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:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
USAID Contractor Employee Physical Examination Form	AID-1420-62

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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	1,460	0	0	1,460	0	0
Annual Time Burden (Hours)	8,760	0	0	8,760	0	0
Annual Cost Burden (Dollars)	249,000	0	0	249,000	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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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: 10/06/2000

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