REV_Supporting_Statement_OMB-0596-0164_20090828

2009 Supporting Statement

OMB 0596-0164

HEALTH SCREENING QUESTIONNAIRE (HSQ)

A. Justification

1. Explain the circumstances that make the col­lection of information necessary. Iden­tify any legal or administrative require­ments that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the col­lection of information.

The Protection Act of 1922 (16 U.S.C. 594) authorizes the Forest Service to fight fires on National Forest System Lands. The individuals that perform as firefighters are subjected to strenuous working conditions requiring long hours of arduous labor. It is imperative that such individuals be in peak physical condition to avoid injury to themselves or their coworkers.

The collection of this information and use thereof are consistent with the provision of 5 USC 552a (Privacy Act of 1974). This gathering and use of this information is outlined in Privacy Act System of Records OPM/GOVT-10 – Employee Medical File System Records, as published annually in the Federal Register under the OPM system of records notice.

2. Indicate how, by whom, and for what pur­pose the information is to be used. Except for a new collec­tion, indicate the actual use the agency has made of the infor­ma­tion received from the current collec­tion.

1. What information will be collected - reported or recorded? (If there are pieces of information that are especially burdensome in the collection, a specific explanation should be provided.)

Information regarding the fitness of applicants for wildfire positions will be collected. The collection of this information is necessary to ensure whether an individual (not currently employed by the Federal government) who is being considered for a position in Wildland Firefighting has the physical ability to perform assigned duties in a manner that will not place the individual or coworkers unduly at risk due to inadequate physical fitness and health.

See Table 1

2. From whom will the information be collected? If there are different respondent categories (e.g., loan applicant versus a bank versus an appraiser), each should be described along with the type of collection activity that applies.

The information will be collected from Forest Service and Department of Interior applicants for wildland firefighter positions; all personnel seeking to complete a Work Capacity Test for the purposes of employment as a wildland firefighter are required to complete the forms.

Table 1

Information Collected	Description	Information Provided to:	Prepared by
FS-5100-30	Work Capacity Test – Informed Consent	Unit employing wildland firefighter	Non-federal employee applicants for Wildland Firefighter positions
FS-5100-31	Health Screening Questionnaire (HSQ)

3. What will this information be used for - provide ALL uses?

This information will be used to determine certification of suitability, special medical or medication needs, and provide a record that will benefit/protect both the individual and the Federal Government if necessary.

4. How will the information be collected (e.g., forms, non-forms, electronically, face-to-face, over the phone, over the Internet)? Does the respondent have multiple options for providing the information? If so, what are they?

Information will be collected via two forms that will be available electronically. The applicant must fill out the forms, sign the paper copy and submit it to the appropriate government official.

4. How frequently will the information be collected?

The information will be collected from individuals seeking wildland firefighting positions. This information is collected once a year from each applicant.

4. Will the information be shared with any other organizations inside or outside USDA or the government?

The information collected will be on file at the duty station of the employee and maintained and shared according to provisions outlined in the Privacy Act. If an individual answers “Yes” to any question on the Health Screening Questionnaire, the form may be shared with Albuquerque Service Center – Human Capital Management (ASC-HCM). This is necessary because a “Yes” answer to any question initiates a requirement for the applicant to complete an SF-78 Certificate of Medical Examination. That process is facilitated by ASC-HCM.

4. If this is an ongoing collection, how have the collection requirements changed over time?

The requirements have not changed.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

Paper copies of forms are available from Forest Service offices as well as the following Department of Interior agencies: the National Park Service, Bureau of Land Management, U.S. Fish and Wildlife Service, and the Bureau of Indian Affairs. Applicants may also access the forms via the Forest Service Internet website, where they may download and fill, print, sign, and mail the form as indicated. The forms are available at these urls: http://www.fs.fed.us/fire/safety/wct/fs_5100_30-1.rtf and http://www.fs.fed.us/fire/safety/wct/2006/5100-31.pdf .

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

This information is collected in association with the administration of an annual physical fitness test. Information related to an individual’s physical health can change over time; it is necessary to collect this information prior to each instance of the test’s administration. Other forms would require much more data to be collected than is necessary, and the collection of such extraneous information would cause an unreasonable burden on both the applicants and program administrators. Further, since the Forest Service and the U.S. Department of the Interior (DOI) agencies involved in wildland firefighting use the same form, these forms are the only forms used for initial assessment of individuals seeking temporary employment as fire fighters by any of those agencies.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

This information collection does not impact small business or other small entities.

6. Describe the consequence to Federal program or policy activities if the collection is not

conducted or is conducted less frequently, as well as any technical or legal obstacles to

reducing burden.

In order to participate in the Work Capacity Test, potential applicants submit a signed copy of FS-5100-30 indicating that they understand the risks involved in participating in the Work Capacity Test.

In order to show that they are physically fit enough to pass the arduous level of the Work Capacity Test, potential applicants must provide the information requested on FS-5100-31 – Health Screening Questionnaire.

Wildland firefighting is seasonal, so the information is only requested at the time the Forest Service and listed DOI agencies hire new employees for these duties. This information collection request only covers members of the public not currently employed by the Forest Service or listed DOI agencies who are applying for employment as Wildland Firefighters.

If this information is not collected, the Government’s liability risk is high, the special needs of applicants may not be known, and the determination regarding the physical suitability of applicants would be greatly inhibited.

7. Explain any special circumstances that would cause an information collection to be

conducted in a manner:

• Requiring respondents to report information to the agency more often than quarterly;

• Requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• Requiring respondents to submit more than an original and two copies of any docu­ment;

• Requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• In connection with a statisti­cal survey, that is not de­signed to produce valid and reliable results that can be generalized to the universe of study;

• Requiring the use of a statistical data classification that has not been reviewed and approved by OMB;

• That includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• Requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

There are no special circumstances. The collection of information is conducted in a manner consistent with the guidelines in 5 CFR 1320.6.

8. If applicable, provide a copy and iden­tify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting com­ments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

The Federal Register 60-Day Public Notice to solicit public comments was published on November 28, 2008 (Federal Register Volume 73, Number 230, pp 72443-72444). No public comments were received in response to this notice.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and record keeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years even if the collection of information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

Michelle Ryerson, Bureau of Land Management, 208-387-5175

Tony Beitia, Bureau of Indian Affairs, 208-387-5177

Chad Fisher, National Park Service, 208-387-5967

9. Explain any decision to provide any payment or gift to respondents, other than reenumeration of contractors or grantees.

No payments or gifts will be given to respondents for completing these forms.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

As per approved Privacy Act System of Record OPM/GOVT-10, Employee Medical File System Records (April 27, 2000, 65 FR 24732), records are located in designated offices within the agency. Records are stored in locked file cabinets or locked rooms. Electronic records are protected by restricted access procedures and audit trails. Access to records is strictly limited to agency or contractor officials with a bona fide need for the records.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior or attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

No information of a sensitive nature (as listed in this item) is being collected.

12. Provide estimates of the hour burden of the collection of information. Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated.

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. If this request for approval covers more than one form, provide separate hour burden estimates for each form.

a) Description of the collection activity

b) Corresponding form number (if applicable)

c) Number of respondents

d) Number of responses annually per respondent,

e) Total annual responses (columns c x d)

f) Estimated hours per response

g) Total annual burden hours (columns e x f)

Table 2

(a) Description of the Collection Activity	(b) Form Number	(c) Number of Respondents	(d) Number of responses annually per Respondent	(e) Total annual responses (c x d)	(f) Estimate of Burden Hours per response	(g) Total Annual Burden Hours (e x f)
Work Capacity Test Informed Consent	FS-5100-30	3,796 (FS)	1	3,796	5 minutes (.083 hour)	315
		1,601 (DOI)		1,601		133
Health Screening Questionnaire	FS-5100-31	3,796 (FS)	1	3,796	5 minutes (.083 hour)	315
		1,601 (DOI)		1,601		133
Totals	---	5,397	---	10,794	---	896

• Record keeping burden should be addressed separately and should include columns for:

a) Description of record keeping activity: None

b) Number of record keepers: None

c) Annual hours per record keeper: None

d) Total annual record keeping hours (columns b x c): None

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories.

Table 3

(a) Description of the Collection Activity	(b) Estimated Total Annual Burden on Respondents (Hours)	(c) Estimated Average Income per Hour	(d) Estimated Cost to Respondents
Work Capacity Test – Informed Consent	448	$7.25	$3,248
Health Screening Questionnaire	448	$7.25	$3,248
Totals	896	---	$6,496

13. Provide estimates of the total annual cost burden to respondents or record keepers resulting from the collection of information, (do not include the cost of any hour burden shown in items 12 and 14). The cost estimates should be split into two components: (a) a total capital and start-up cost component annualized over its expected useful life; and (b) a total operation and maintenance and purchase of services component.

There are no start-up/capital or operation and maintenance costs associated with this collection.

14. Provide estimates of annualized cost to the Federal government. Provide a description of the method used to estimate cost and any other expense that would not have been incurred without this collection of information.

The response to this question covers the actual costs the agency will incur as a result of implementing the information collection. The estimate should cover the entire life cycle of the collection and include costs, if applicable, for:

• Employee labor and materials for developing, printing, storing forms

• Employee labor and materials for developing computer systems, screens, or reports to support the collection

• Employee travel costs

• Cost of contractor services or other reimbursements to individuals or organizations assisting in the collection of information

• Employee labor and materials for collecting the information

• Employee labor and materials for analyzing, evaluating, summarizing, and/or reporting on the collected information

Table 4

ACTION ITEM	PERSONNEL	GS LEVEL	HOURLY RATE*	HOURS	SALARY
Staff hours to review applications		9	$19.62	20,000	$392,400
Personnel Analyst hours to assure form is part of hiring package		13	$33.84	6,800	$230,112
Total Cost to Government					$622,512

15. Explain the reasons for any program changes or adjustments reported in items 13 or 14 of OMB form 83-I.

Since the last submission there is an increase of 20 burden hours as a result of an increase in the number of applicants.

16. For collections of information whose results are planned to be published, outline plans for tabulation and publication.

Publication of information collected is not planned.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

No intent to have exemption from expiration date.

18. Explain each exception to the certification statement identified in item 19, "Certification Requirement for Paperwork Reduction Act."

The Forest Service and Department of the Interior are able to certify compliance with all provisions.

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