0596-0164 2013 renwal Supporting Statement v01-14-13

2013 Supporting Statement for OMB 0596-0164

HEALTH SCREENING QUESTIONNAIRE (HSQ)

Terms of Clearance: There are no terms of clearance for the current OMB approval

A. Justification

1. Explain the circumstances that make the col­lection of information necessary. Iden­tify any legal or administrative require­ments that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the col­lection of information.

The Protection Act of 1922 (16 U.S.C. 594) authorizes the Forest Service to fight fires on National Forest System Lands. The individuals that perform as firefighters are subjected to strenuous working conditions requiring long hours of arduous labor. It is imperative that such individuals be in peak physical condition to avoid injury to themselves or their coworkers.

The collection of this information is necessary to ensure whether an individual (not currently employed by the Federal government) who is being considered for a position in Wildland Firefighting has the physical ability to perform assigned duties in a manner that will not place the individual or coworkers unduly at risk due to inadequate physical fitness and health.

The Forest Service and Department of the Interior wildland fire management agencies administer a Health Screening Questionnaire (HSQ) to prospective wildland firefighters in order to pre-identify health risk factors. For safety reasons, this is important to determine before employees and applicants are subjected to arduous physical fitness tests. The HSQ allows the Forest Service to clear healthy individuals to take the fitness tests without further examination, because it identifies people with health risk factors and sends them for medical examination before fitness testing is allowed.

Use of the HSQ saves the government significant money and the public significant burden, since it allows for health screening to occur without every employee or applicant having to submit to a medical examination. It would be prohibitively expensive and unnecessary to give all of our employees a medical exam annually.

The collection of this information and use thereof are consistent with the provision of 5 USC 552a (Privacy Act of 1974). This gathering and use of this information is outlined in Privacy Act System of Records OPM/GOVT-10 – Employee Medical File System Records, as published annually in the Federal Register under the OPM system of records notice.

2. Indicate how, by whom, and for what pur­pose the information is to be used. Except for a new collec­tion, indicate the actual use the agency has made of the infor­ma­tion received from the current collec­tion.

1. What information will be collected - reported or recorded? (If there are pieces of information that are especially burdensome in the collection, a specific explanation should be provided.)

Information regarding the fitness and medical history of applicants for wildfire positions will be collected.

Personnel who complete the Health Screening Questionnaire answer either “Yes” or “No” to nine questions about their health and medical status. If a person answers “Yes” to any of these nine questions, they are sent for an agency-provided medical examination using the Office of Personnel Management’s OF-178 Form. The OF-178 Form is an OMB approved form (OMB No. 3206 – 0250). The title of the form is “Certificate of Medical Examination” and as such it is the U.S. Government-approved form for work-related medical examinations. The purpose of the HSQ is to identify who among our employees needs to complete an OF-178 versus who can be approved to take the Work Capacity Test “as is.”

2. From whom will the information be collected? If there are different respondent categories (e.g., loan applicant versus a bank versus an appraiser), each should be described along with the type of collection activity that applies.

The information will be collected from applicants for wildland firefighter positions; all personnel seeking to complete a Work Capacity Test for the purposes of employment as a wildland firefighter are required to complete the forms. Only those personnel who answer “Yes” to one of the nine questions on the HSQ will be sent for a medical examination using the OF-178 form. In 2011 the percentage of people referred for an OF-178 medical exam after completing an HSQ was 17% for the Forest Service applicants.

3. What will this information be used for - provide ALL uses?

This information will be used to determine certification of suitability, special medical or medication needs, and provide a record that will benefit/protect both the individual and the Federal government, if necessary.

4. How will the information be collected (e.g., forms, non-forms, electronically, face-to-face, over the phone, over the Internet)? Does the respondent have multiple options for providing the information? If so, what are they?

Information will be collected via the FS-5100-30 Work Capacity Test – Informed Consent and FS-5100-31 Health Screening Questionnaire forms that will be available by paper copy from Forest Service offices or to download from the Forest Service Internet website. The applicant must fill out the forms, sign the paper copy and submit it to the appropriate government official in person, by mail or fax. Signed and scanned forms may also be sent electronically by email.

4. How frequently will the information be collected?

The information will be collected from individuals seeking wildland firefighting positions. This information is collected once a year from each applicant prior to taking the Work Capacity Test.

Wildland firefighting is seasonal, so the information is only requested at the time the Forest Service and listed Department of the Interior bureaus hire new employees for these duties. This information collection request only covers members of the public not currently employed by the Forest Service or listed DOI bureaus who are applying for employment as Wildland Firefighters.

4. Will the information be shared with any other organizations inside or outside USDA or the government?

In the event that an individual answers “Yes” to any question on the Health Screening Questionnaire, the form may be shared with Forest Service’s Albuquerque Service Center – Human Capital Management (ASC-HCM). This is necessary because a “Yes” answer to any question initiates a requirement for the applicant to complete an OF-178 Certificate of Medical Examination, and that process is facilitated by ASC-HCM.

4. If this is an ongoing collection, how have the collection requirements changed over time?

The requirements have not changed over time.

3. Describe whether, and to what extent, the collection of information involves the use of auto­mat­ed, elec­tronic, mechani­cal, or other techno­log­ical collection techniques or other forms of information technol­o­gy, e.g. permit­ting elec­tronic sub­mission of respons­es, and the basis for the decision for adopting this means of collection. Also describe any con­sideration of using in­fo­r­m­a­t­ion technolo­gy to re­duce bur­den.

Paper copies of forms are available from Forest Service offices. Applicants may also access the forms via the Forest Service Internet website, where they may download and fill out the form, print out the form, sign and mail, scan and email or fax the form as indicated. A system to submit the forms electronically has not been developed at this time.

4. Describe efforts to identify duplica­tion. Show specifically why any sim­ilar in­for­mation already avail­able cannot be used or modified for use for the purpos­es de­scri­bed in Item 2 above.

This information is collected in association with the administration of an annual physical fitness test. Forest Service and the Department of the Interior Bureaus involved in wildland firefighting use the same form, and these forms will be the only ones used for initial assessment of individuals seeking temporary employment as fire fighters by any of these organizations.

5. If the collection of information im­pacts small businesses or other small entities, describe any methods used to mini­mize burden.

This information collection does not impact small business or other small entities.

6. Describe the consequence to Federal program or policy activities if the collection is not conducted or is con­ducted less fre­quent­ly, as well as any technical or legal obstacles to reducing burden.

In order to participate in the Work Capacity Test, potential applicants submit a signed copy of FS-5100-30 to show that they understand the risks involved in participating in the Work Capacity Test.

In order to show that they are physically fit enough to pass the Work Capacity Test, potential applicants must provide the information requested on FS-5100-31 – Health Screening Questionnaire.

If this information is not collected, the Government’s liability risk is high, the special needs of applicants may not be known, and the determination regarding the physical suitability of applicants would be greatly inhibited.

7. Explain any special circumstances that would cause an information collecti­on to be con­ducted in a manner:

• Requiring respondents to report informa­tion to the agency more often than quarterly;

• Requiring respondents to prepare a writ­ten response to a collection of infor­mation in fewer than 30 days after receipt of it;

The FS-5100-30 Informed Consent and FS-5100-31 Health Screening Questionnaire forms will be provided more than 30 days in advance of receipt whenever possible. Due to the emergency nature of wildland firefighting, in some cases the forms may be provided with fewer than 30 days to complete, to meet the immediate need to hire wildland firefighters in an emergency.

• Requiring respondents to submit more than an original and two copies of any docu­ment;

• Requiring respondents to retain re­cords, other than health, medical, governm­ent contract, grant-in-aid, or tax records for more than three years;

• In connection with a statisti­cal sur­vey, that is not de­signed to produce valid and reli­able results that can be general­ized to the uni­verse of study;

• Requiring the use of a statis­tical data classi­fication that has not been re­vie­wed and approved by OMB;

• That includes a pledge of confidentiality that is not supported by au­thority estab­lished in statute or regu­la­tion, that is not sup­ported by dis­closure and data security policies that are consistent with the pledge, or which unneces­sarily impedes shar­ing of data with other agencies for com­patible confiden­tial use; or

• Requiring respondents to submit propri­etary trade secret, or other confidential information unless the agency can demon­strate that it has instituted procedures to protect the information's confidentiality to the extent permit­ted by law.

There are no other special circumstances. The collection of information is conducted in a manner consistent with the guidelines in 5 CFR 1320.6.

8. If applicable, provide a copy and iden­tify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting com­ments on the information collection prior to submission to OMB. Summarize public com­ments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address com­ments received on cost and hour burden.

The Federal Register 60-Day Public Notice to solicit public comments on this information collection was published on July 6, 2012, 77 FR 39986-39987. One Public comment was received from the Department of Health and Human Services, Public Health Service, National Institute for Occupational Safety and Health (NIOSH).

NIOSH detailed suggested changes to the HSQ making some of the questions more detailed and complicated; suggested more respondents be required to be medically examined than currently examined under the current program; and also suggested that the HSQ be administered by health care providers.

Some of the suggested changes would increase the burden on the respondents. Forest Service will take the NIOSH suggestions under advisement, and will be addressed at a future date directly with NIOSH.

Describe efforts to consult with persons out­side the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and record keeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years even if the col­lection of information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

William Worthwine, Bureau of Land Management, 208-384-3403

William Arsenault, Private Individual, Firefighter as Needed, 208-830-9465

Michelle Neihoff, Boise National Forest, HSQ Administrator, 208-392-6681

Consultation included discussion with a Work Capacity Test program Administrator, a member of the public qualified for employment as a wildland firefighter, and an employee who compiles FS-5100-30 and FS-5100-31 forms. It was indicated that these forms are easily obtainable from the internet or from agency offices, the instructions are clear and that completion once a year is not an unreasonable burden.

9. Explain any decision to provide any payment or gift to respondents, other than re-enumeration of contractors or grantees.

No payments or gifts will be given to respondents for completing these forms.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

As per approved Privacy Act System of Record OPM/GOVT-10, Employee Medical File System Records (April 27, 2000, 65 FR 24732), records are located in designated offices within the agency. Records are stored in locked file cabinets or locked rooms. Electronic records are protected by restricted access procedures and audit trails. Access to records is strictly limited to agency or contractor officials with a bona fide need for the records.

The following language is found on the form itself:

“The information obtained in the completion of this form is used to help determine whether an individual being considered for wildland firefighting can carry out those duties in a manner that will not place the candidate unduly at risk due to inadequate physical fitness and health. Its collection and use are covered under Privacy Act System of Records OPM/Govt-10 and are consistent with the provisions of 5 USC 552a (Privacy Act of 1974).”

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior or attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

The medical information requested from respondents may be considered sensitive. The information that is collected only includes applicant medical and personal fitness information that is directly related to the physical demands of a wildland firefighting position prior to the administration of a physical fitness test. Collection of this information assists the Government to determine if an applicant is physically suited to take the Work Capacity Test. For potential wildland firefighter applicants, taking and passing the Work Capacity Test is a condition of hire outlined in their pre-employment paperwork. Potential applicants are advised that all responses are of a confidential nature.

12. Provide estimates of the hour burden of the collection of information. Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated.

For the estimated total number of responses, hour burden, and cost to respondents, please see enclosed supplemental document entitled 0596-0164 2013 Burden Spreadsheet.

Table 1: Total Forms Collected 2010 - 2012

(a) Collection Activity	(b) Form Number	Response Year	Total Responses/year
Work Capacity Test Informed Consent Health Screening Questionnaire	FS-5100-30 FS-5100-31	2010	6,988 (FS)
			4,993 (DOI)
		2011	7,197 (FS)
			5,142 (DOI)
		2012	7,916 (FS)
			5655 (DOI)

Table 1 above shows how many wildland firefighting candidates completed the FS-5100-30 and FS-5100-31 forms in order to obtain clearance for the Work Capacity Test. The totals above were calculated by querying the Incident Qualifications and Certification System (IQCS), the interagency training and qualification database of record.

The estimate of number of respondents was calculated by querying the Incident Qualifications and Certification System (IQCS), the interagency training and qualification database of record and using the average of each of the last three years’ number of respondents.

A total of 660 OF-178 Medical Examination forms were completed by Forest Service personnel in Fiscal Year 2011. This number amounted to 17% of the total HSQ forms administered; thus the number of Dept. of Interior OF-178 forms are estimated to be 17% of their HSQ totals as well.

The estimate of Burden hours per response was obtained by consultation with WCT administration personnel who have personally observed the completion of these forms for the previous five years.

There is no record keeping requirement placed upon the respondents as part of this information collection.

The estimate of annualized cost to respondents Income Source: Bureau of Labor Statistics Category 33-2011, Firefighters http://www.bls.gov/oes/current/oes332011.htm

13. Provide estimates of the total annual cost burden to respondents or record keepers resulting from the collection of information, (do not include the cost of any hour burden shown in items 12 and 14). The cost estimates should be split into two components: (a) a total capital and start-up cost component annualized over its expected useful life; and (b) a total operation and maintenance and purchase of services component.

There are no capital operation and maintenance costs.

14. Provide estimates of annualized cost to the Federal government. Provide a description of the method used to estimate cost and any other expense that would not have been incurred without this collection of information.

The response to this question covers the actual costs the agency will incur as a result of implementing the information collection. The estimate should cover the entire life cycle of the collection and include costs, if applicable, for:

• Employee labor and materials for developing, printing, storing forms

• Employee labor and materials for developing computer systems, screens, or reports to support the collection

• Employee travel costs

• Cost of contractor services or other reimbursements to individuals or organizations assisting in the collection of information

• Employee labor and materials for collecting the information

• Employee labor and materials for analyzing, evaluating, summarizing, and/or reporting on the collected information

To estimate the estimated staff and personnel hours, the total number of forms received was multiplied against the time required to review applications, and assure forms are part of the hiring package, and complete recordkeeping tasks. It was determined after consultation with staff that the time required to review was similar to the time to complete the form; 5 minutes each. As the forms have not changed recently, there are no additional costs to review the form content. Once the forms are completed on the base unit, no additional analysis or evaluation of the data is required.

Table 2 Estimated Cost to Government

ACTION ITEM	MATERIALS	GS LEVEL	HOURLY RATE*	HOURS	SALARY
Staff hours to review applications		7	18.59	2,096	$34,123
Personnel Analyst hours to assure form is part of hiring package		11	27.51	2,096	$50,514
Employee labor and materials for developing, printing and storing forms	$3000	9	22.74	2,096	$47,663
Total					135,300

* Table 2 above displays the estimated cost to the government, based on average hourly salaries of $18.59 for a GS-7, Step 1 federal employee; $27.51 for a GS-11, Step 1; and $22.74 for a GS-9, Step 1. These hourly wages are multiplied by the estimated number of hours per year.

This estimate is derived from the U.S. Office of Personnel Management Salaries and Wages 2011 Salary Table for General Schedule federal employees http://www.opm.gov/oca/12tables/html/RUS_h.asp

Materials costs are estimated, taking into account paper, printing and mailing costs with storage in government facilities.

15. Explain the reasons for any program changes or adjustments in respondent hour or cost burden.

Adjustments in the estimate of the number of respondents are based on analysis of the previous 3-year period of records (2010-2012). Based on this analysis, the number of respondents has increased from 5,397 to 12,630 respondents per year.

Adjustments in the burden estimate are due to an increase in the estimated number of respondents, and additionally now reflect a 5-minute estimate for EACH form, both the HSQ and the Informed Consent; the previous request only identified burden hours associated with completion of the HSQ itself. This has resulted in an increase in the estimate of burden hours from 896 to 2,097 hours.

16. For collections of information whose results are planned to be published, outline plans for tabulation and publication.

Publication of information collected is not planned.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

The valid OMB control number and expiration date will be displayed on all forms.

18. Explain each exception to the certification statement identified in item 19, "Certification Requirement for Paperwork Reduction Act."

The agency is able to certify that the collection of information encompassed by this request complies with 5 CFR 1320.

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