Medical Clearance Update

Forms and Documents

Document Name	Status
Form DS03057 Medical Clearance Update Form and Instruction	Modified
Legal Authorities_Ds 3057_06_08.docx Supplementary Document	2010-12-02
Supporting Statement_DS 30.docx Supporting Statement A	2010-12-02

IC Document Collections

IC ID	Document Title	Status
15003	Medical Clearance Update Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0131	ICR Reference No: 201012-1405-001
Status: Historical Active	Previous ICR Reference No: 200809-1405-002
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical Clearance Update
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/09/2011
	Date Received in OIRA: 12/02/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2014	36 Months From Approved	11/30/2011
Responses	9,800	0	9,800
Time Burden (Hours)	4,900	0	4,900
Cost Burden (Dollars)	0	0	0

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Abstract: Information is collected for the purpose of making a decision regarding the clearance status of an individual and family members for assignment abroad. Information collected is required to determine assignment status, what country and city assignments are appropriate for the medical care needs of the individual and family members and the medical care available in the country and city of the proposed assignment.

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Authorizing Statute(s): US Code: 22 USC 3901 Name of Law: Foreign Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 195	10/08/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 231	12/02/2010
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
Medical Clearance Update	DS03057	Medical Clearance Update

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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	9,800	9,800	0	0	0	0
Annual Time Burden (Hours)	4,900	4,900	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

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: $2,353,276

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 12/02/2010

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