Report of Medical Examination and Vaccination Record

Forms and Documents

Document Name	Status
Form Form I-693 Report of Medical Examination and Vaccination Record Form	Modified
Form I-693 PRA Notice Supporting Statement 9-10-12.doc Supporting Statement A	2012-09-10
I693-INS-TOC-8162012.doc Supplementary Document	2012-09-07
I693-FRM-TOC-08162012.doc Supplementary Document	2012-09-07
Reference citations 6-4-12.doc Supplementary Document	2012-09-07
SORN - United States Citizenship and Immigration Services Benefits Information System.doc Supplementary Document	2012-09-07
PIA.pdf Supplementary Document	2012-09-07
Published 30-Day Notice 9-7-12.pdf Supplementary Document	2012-09-07
Published 60-day notice 6-18-2012.pdf Supplementary Document	2012-09-07

IC Document Collections

IC ID	Document Title	Status
20305	Report of Medical Examination and Vaccination Record Form	Modified

ICR Details

OMB Control No: 1615-0033	ICR Reference No: 201209-1615-001
Status: Historical Active	Previous ICR Reference No: 201107-1615-005
Agency/Subagency: DHS/USCIS	Agency Tracking No: I-693
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: 01/15/2013
	Date Received in OIRA: 10/31/2012
Terms of Clearance: Approved for two years only due to lack of GPEA compliance.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	36 Months From Approved	01/31/2013
Responses	565,180	0	800,000
Time Burden (Hours)	1,412,950	0	2,000,000
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): US Code: 8 USC 1255 Name of Law: Immigration and Nationality 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:
	77 FR 36285	06/18/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 55221	09/07/2012
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
Report of Medical Examination and Vaccination Record	Form I-693	Report of Medical Examination and Vaccination Record

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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	565,180	800,000	0	0	-234,820	0
Annual Time Burden (Hours)	1,412,950	2,000,000	0	0	-587,050	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: There has been a decrease of 587,050 in burden hours from those previously reported for this information collection. This change can be attributed to a decrease in the number of respondents from 800,000 respondents to 565,180. The decrease in the number of respondents is based on updated FY 2011 statistical data and the resulting adjustment in agency estimates.

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Annual Cost to Federal Government: $33,910,800

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: 10/31/2012

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