SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION
Medical History And
Examination For Foreign Service, OMB # 1405-0068,
Form DS-1622, and Form DS-1843
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 220, paragraph b, the medical program provides medical examinations for applicants for employment and also medical examinations as necessary for members of the Foreign Service, other Federal Agencies 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.
The information requested on the DS-1622 and DS-1843 is required for professional medical staff of the Office 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.
The DS-1622 and DS-1843 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. The Office of Medical Services is actively evaluating the Department of Defense (DOD) and the Veterans Administration (VA) EMR software programs to explore the possibility of full integration of DS-1622 and DS-1843 into the EMR system.
With the exception of basic identification and contact information other information is not duplicative. 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-1622 and DS-1843 Medical History And Examination For Foreign Service form allows comparison of salient health conditions from one clearance update to another without necessitating a physical examination.
This collection of information does not impact small businesses or other small entities.
Not collecting the required information on the DS-1622 and DS-1843 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.
There are no special circumstances that would require the information to be collected in the manner described in the instructions for the supporting statement.
A 60 day public notice was published in the Federal Register and no comments were received. Consultations from persons outside the agency were not made. The information required on the form is medically necessary information required to make an assignment or clearance determination. The staff of medical clearances routinely reviews the requirements for the information collection to ensure that the information required is timely, represents an accurate picture of the health of the respondent, and is necessary for the decision making process.
The Department does not make any type or form of payment to the respondent.
Medical records and other medical information identified to a particular individual are governed under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191. This act states that private health information, as defined in the Act, may only be released to third parties with the consent of the subject individual. As such, no restricted medical information is released to third parties without the written consent of the individual. With the Privacy Act Statement included, there is further assurance of confidentiality as governed by Title 5 U.S.C. 552A.
These forms require a Foreign Service Officer, Federal employee 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 limited. The form also requires a discussion regarding any special educational needs that a dependent child may have; this too would preclude some posts for consideration for overseas assignment.
The following data was used in the preparation of the hour burden for the collection of the information required by the form:
a. Number of Respondents: 7,234 per year. [Numbers provided by Medical Records from 2007, 4,322 in-service clearances for spouses, children, and 4,322 new applicants to the Foreign Service per year.]
b. Number of Responses: 7,234 per year (DS 1622 was 3,617 and DS 1843 was 3,617)
c. Frequency of Response: On occasion. Minimum every three years; maximum between tours of duty
d. Annual hour burden: 7,234 hours. The annual burden was estimated using a percentage of the actual number of medical clearances issued in FY07. It is estimated that a respondent must spend an hour gathering the information, transcribing the information, and submitting the form. The burden estimate was lowered from the previous burden of 9,800 hours to current 7,234 hours based on the lower number of applicants and personnel requiring medical clearances.
13. Cost of hour burden to the record keeper and respondent is zero.
14. Total cost to the Federal Government is $364,361.58. This was determined using the cost of $3.17 per form for processing medical examination documents and scanning additional medical information as required for 7,234 pages x four pages per collection. The labor cost to process the form is estimated at $12.76 per form. The cost of processing the form is 7,234 forms x $12.76 per form, or $92,305.84. Adding both costs together for the printing and the scanning cost of $272,055.74, the total cost is therefore $364,361.58.
15. The number of respondents to this collection has decreased since the last renewal as a better estimate of the numbers of spouses, children, and new employees was obtained.
16. The information collected will not be published or routinely tabulated. The only tabulation that is required is the total number of clearances issued.
17. The Office of Medical Services will display the OMB expiration date on the forms.
18. No exceptions to the certification statement identified in OMB Form 83-I, item 19 have been identified.
This collection does not employ statistical methods in the collection process nor in the use of the information collected.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR |
| Author | USDOS |
| Last Modified By | oitsharp |
| File Modified | 2009-01-13 |
| File Created | 2009-01-13 |