Medical History and Examination for Foreign Service

Forms and Documents

Document Name	Status
Form DS-1622 Medical History and Examination for Foreign Service Form and Instruction	Modified
Policy Memo on MED Clearance Forms (8-29-2013).pdf Supplementary Document	2013-09-11
Justification for Emergency Review revised (8.28.13).docx Supplementary Document	2013-09-11
Justification for Emergency Review.docx Supplementary Document	2013-08-16
LegalAuthorities.docx Supplementary Document	2013-08-16
Medical Forms Supporting Statement rev 2 (9-9-13).docx Supporting Statement A	2013-09-11

IC Document Collections

IC ID	Document Title	Status
14884	Medical History and Examination for Foreign Service Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0068	ICR Reference No: 201308-1405-006
Status: Historical Active	Previous ICR Reference No: 201109-1405-003
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical History and Examination for Foreign Service
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 08/23/2013
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/11/2013
	Date Received in OIRA: 08/16/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	6 Months From Approved	02/28/2015
Responses	23,245	0	8,000
Time Burden (Hours)	23,245	0	8,000
Cost Burden (Dollars)	0	0	0

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Abstract: Pursuant to 22 U.S.C. § 4084, the Secretary of State has the authority to establish a Medical Program. This information collection provides to the U.S. Department of State's Office of Medical Services the material needed to determine whether a candidate for a Foreign Service appointment is able to obtain the medical clearance that is a requirement for that appointment, and to determine the appropriate medical clearances for other individuals who participate in the Medical Program.

Emergency Justfication: The information collected in Form DS-1843 is needed to determine whether a candidate for a Foreign Service appointment can obtain the medical clearance that is a requirement of the appointment. Additionally, the information collected in Forms DS-1843 and DS-1622 is used to provide and to update medical clearances for individuals who participate in the Department of State’s Medical Program. The information collection is essential to the mission of the Foreign Service, and form revisions are needed to clarify that the information collection is consistent with applicable authorities.

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Authorizing Statute(s): PL: Pub.L. 110 - 233 122 Name of Law: Genetic Information Nondiscrimination Act of 2008
  

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:
	78 FR 159	08/16/2013
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 History and Examination for Foreign Service	DS-1622 , DS-1843	Medical History and Examination for Foreign Service (For Children 11 Years and Under) ,   Medical History and Examination for Foreign Service (For Individuals Age 12 and Over)

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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	23,245	8,000	0	15,245	0	0
Annual Time Burden (Hours)	23,245	8,000	0	15,245	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The number of respondents has had a significant increase since 2011 when the Office of Medical Clearances processed approximately 8,000 clearances.Changes on the form are due to meeting the requirements of GINA (Genetic Information Nondiscrimination Act of 2008).

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Annual Cost to Federal Government: $373,081

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: 08/16/2013

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