SUPPORTING
STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION
OMB
Control No. 1405-0068
(DS-1843, DS-1622, DS-1843P, & DS-1622P)
Under the authority of 22 U.S.C. 4084, the Secretary of State has the authority to establish a medical program. As specified in 16 FAM 211, the medical program provides medical examinations for applicants for employment and also medical examinations as necessary for members of the Foreign Service and employees of the Department and their families. 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. (Note: For purposes of the Paperwork Reduction Act, only non-employees are considered “respondents” regarding this information collection.)
The information requested on the DS-1843, DS1843P, DS-1622, and DS-1622P is required to provide professional medical personnel with the medical information necessary to make decisions on the type of medical clearance an individual, and family members, is 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 if medical privacy statutes and regulations do not otherwise protect the information.
Electronic versions of the forms are available on the Department’s website. Current practice is for the form to be printed, signed, and sent to Medical Records [email protected]. The forms are then scanned as an image into our Electronic Medical Record (EMR). The Department is implementing an electronic forms package that will allow the Office of Medical Services to use electronic submission of information via the electronic form directly into our Electronic Medical Record (EMR) through the internet, intranet, and via direct scanning of the form.
Although information may appear to be duplicated with other collection instruments, it generally is not, with the exception of basic identification and contact information. Address, agency, type of employment, and other information can routinely change during the periods between medical clearance updates. Family members, in particular, may change status, type of employment, and other aspects of the information that is collected. The medical information collected will routinely change with each medical clearance update. Use of the forms for recording medical histories and the results of physical exams allows for comparison of salient health conditions from one clearance update to another. The Department medical providers may determine that additional tests are required based upon the information collected on these forms.
This collection of information does not impact small businesses or other small entities.
Not collecting the required information on the forms will result, in some cases, in assignment of medically unqualified Foreign Service Officers 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 or medical clearance update is every two years or home leave whichever is shorter. This frequency is set to be the least burdensome on the respondent, while still allowing the Department to issue accurate medical clearances.
There are no circumstances that would require the information to be collected in the manner described in the instructions for the supporting statement.
A 60-day notice was published in the Federal Register on 25 June 2010 in Volume 75, Number 122 to elicit public comments. Consultations with 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. No comments were received.
The Department does not make any type or form of payment to the respondent.
Medical records and other medical information identified with a particular individual are governed under the Health Insurance Portability and Accountability Act of 1996, 26 U.S.C., Subtitle K. 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 or family member to provide information regarding his/her medical history, including information regarding mental health status, past mental health treatment, and chronic medical conditions. (Only non-employees are considered “respondents” for PRA purposes.) Although not routinely discussed, except with a person’s health care provider, these questions are necessary to gauge the individual and family members’ capability to be assigned to hardship posts or posts where stressors are severe. The information contained in the forms is necessary for a medical professional to make a decision regarding the ability to send a government employee and his/her family overseas.
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: 8,000 per year.
b. Number of Responses: 8,000 per year
c. Frequency of Response: On entrance to the Foreign Service and on occasion afterwards.
d. Annual hour burden: 8,000 hours. The annual burden was estimated based upon the number of respondents and an estimate of one hour to gather the information, transcribe the information, print and sign the form, and send it to Medical Clearances.
13. There are no costs to respondents associated with this collection (other than the hour burden described in Item 12).
14. Total cost to the Federal Government is $478,176. The printing cost, ($0.03 per page) for 32,000 pages (8,000 responses x four pages per response) is $960.00. The scanning cost to process the form into our Electronic Medical Record System is estimated at $3.17 per form for a total of $101,440) per year. The cost of processing the form is estimated at $12.76 per form multiplied by 32,000 forms or $408,320.00 per year. Adding all costs together, the total cost of this form to the Federal Government is $510,820.
15. The estimated number of respondents to this collection has increased from 7,500 to 8,000 based on increases in accession into the Foreign Service. This represents a program adjustment.
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 is not seeking approval to remove the OMB date from the form.
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/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SUPPORTING STATEMENT FOR |
| Author | USDOS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |