Supporting Statement DS3057 (4-14)

SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION
OMB # 1405-0131, DS-3057

A. JUSTIFICATION

1. Under the authority of the Foreign Service Act of 1980 (22 U.S.C. 3901) and the Basic Authorities Act of 1956 (22 U.S.C. 2651), the Secretary has the ability to establish a medical program. As specified in Volume 16 of the Foreign Affairs Manual (FAM), specifically 16 FAM 220, paragraph b, 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 eligible family members. 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.

2. The Medical Clearance Update form (DS-3057) is completed by members of the Foreign Service and employees of the Department and their eligible family members. The information requested on the DS-3057 is required for professional clinical staff of the Office of Medical Services to make decisions on the type of medical clearance an individual and family members are assigned. 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 once a certified need is determined and if medical privacy statutes and regulations do not otherwise protect the information.

3. The DS-3057 is available throughout the Department of State via the e-Forms electronic forms application. The form is scanned as an image into the DOS Electronic Medical Record (EMR). At this time, there is no electronic submission capability that automatically integrates this information collection into the EMR or our Medical Clearances software application. The Office of Medical Services is actively developing an EMR program with the U.S. Coast Guard. Estimated completion date is sometime in 2015.

4. Although information may appear to be duplicated with other collection instruments, it generally is not, with the exception of basic identification and contact information. Addresses, agency, type of employment, and other information can routinely change during the periods between the medical clearance update. Family members in particular may change status, type of employment, and other information that is collected. Medical information required will routinely change from medical clearance update to update. Use of the DS-3057 Medical Clearance Update form allows comparison of salient health conditions from one clearance update to another without necessitating a physical examination.

5. This collection of information does not impact small businesses or other small entities.

6. Not collecting the required information on the DS-3057 will result in an inability to determine appropriate medical clearances. 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 is at the end of an assignment or home leave, whichever is shorter. This frequency serves the Department well and obtains the required information at the time that it is needed and not before.

7. There are no circumstances that would require the information to be collected in the manner described in the instructions for the supporting statement.

8. On October 29, 2013, a 60-day notice was published in the Federal Register, 78 FR 64574, to elicit public comments. On December 23, 2013, a comment from the U.S. Equal Employment Opportunity Commission was submitted to regulations.gov. The Office of Medical Services did not receive notice of the comment until after the period for comments had closed and was unable to directly retrieve the comment. However, the EEOC forwarded the comment via email, and the comment was then considered. The Department believes that the form, as amended, is consistent with applicable laws and regulations.

9. The Department does not make any type or form of payment to the respondent.

10. Medical records and other medical information identified to a particular individual are governed under the Privacy Act of 1974. The Office of Medical Services is authorized to collect this health information pursuant to section 904 of the Foreign Service Act, 22 U.S.C. § 4084. With the Privacy Act Statement included, there is further assurance of privacy as governed by Title 5 U.S.C. 552A.

11. This form requires a Foreign Service Officer, Federal employee or family member to provide information regarding mental health status, past mental health treatment, and chronic medical conditions. Although not routinely discussed, except with a person’s health care provider, these questions are necessary to determine the appropriate medical clearance for the individual and family members.

12. The Department of State Office of Medical Services estimates the hour burden of 8,140 hours per year.
    
    The number of respondents per year is approximately 16,280. This estimate is based on 55% of 29,600 clearances for spouses, children, and new applicants to the Foreign Service in FY12. These forms are required intermittently through each Foreign Service employee’s career.
    
    The annual burden was estimated based upon the number of respondents and an estimate of one half hour to gather the information, transcribe the information, print and sign the form, and send it to Medical Clearances.

13. Cost of hour burden to the record keeper is zero.

14. Total cost to the Federal Government is $275,132.

The print cost was determined to be $1,628 by using the cost of $0.05 per page for printing on a laser printer times 16,280 two page forms.

The labor cost was estimated to be $273,504 based on the hour burden of 8,140 hours x $33.60/hour. $33.60 was determined using the U.S. Department of Labor, Bureau of Labor Statistics website (www.bls.gov) since the average mean hourly civilian earnings on July 2013 was $23.98/hr., rounded to $24.00 then multiplied by 1.4 for a weighted hourly wage of $33.60.

Adding both costs together for the printing and the processing cost, the total cost is therefore $275,132.

15. The average number of respondents has increased from 9,800 to 16,280. As a result of this increase in respondents, the hour burden has increased from 4,900 to 8,140.

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 will display the OMB date on the form.

18. No exceptions to the certification statement identified in OMB Form 83-I, item 19 have been identified.

B. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS

This collection does not employ statistical methods in the collection process nor in the use of the information collected.