Report of Medical Examination and Vaccination Record

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form I-693 Report of Medical Examination and Vaccination Record	Form	Modified	Available
I-693 Supp Statement 9-29-11.doc	Supporting Statement A	Uploaded 2011-10-04	Available
I-693 TOC 04-27-2011.doc	Supplementary Document	Uploaded 2011-07-14	Available
SORN - United States Citizenship and Immigration Services Benefits Information System.doc	Supplementary Document	Uploaded 2011-07-14	Available
Reference citations.doc	Supplementary Document	Uploaded 2011-07-14	Available
PIA.pdf	Supplementary Document	Uploaded 2011-07-14	Available
Published 30-Day Notice 7-13-11.doc	Supplementary Document	Uploaded 2011-07-14	Available
60-Day Notice 5-13-11 67 FR 24908.pdf	Supplementary Document	Uploaded 2011-07-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
20305	Report of Medical Examination and Vaccination Record	Form	Modified

ICR Details

OMB Control No: 1615-0033	ICR Reference No: 201107-1615-005
Status: Historical Active	Previous ICR Reference No: 201006-1615-005
Agency/Subagency: DHS/USCIS	Agency Tracking No:
Title: Report of Medical Examination and Vaccination Record
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/11/2011
	Date Received in OIRA: 07/26/2011
Terms of Clearance: Approved for one year only due to lack of GPEA compliance.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2012	36 Months From Approved	10/31/2011
Responses	800,000	0	800,000
Time Burden (Hours)	2,000,000	0	2,000,000
Cost Burden (Dollars)	0	0	0

---

Abstract: The information on the application will be used by USCIS in considering eligibility for adjustment of status under 8 CFR part 209, 8 CFR 210.5, 245.1 and 245a.3.

---

Authorizing Statute(s): US Code: 8 USC 1255 Name of Law: Immigration and Nationality Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 24908	05/03/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 41282	07/13/2011
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Report of Medical Examination and Vaccination Record	I-693	Report of Medical Examination and Vaccination Record

---

ICR Summary of Burden

table that charts list 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	800,000	800,000	0	0	0	0
Annual Time Burden (Hours)	2,000,000	2,000,000	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:

---

Annual Cost to Federal Government: $48,027,500

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

---

Common Form ICR:  No

---

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: 07/26/2011

---