SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION
OMB # 1405-0194,
DS-6561
Pursuant to the Foreign Service Act of 1980 (22 U.S.C. §§ 3901, 4084) and the Basic Authorities Act of 1956 (22 U.S.C. § 2651), the Secretary 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 the appropriate medical clearances for non-Foreign Service personnel who may participate in the Medical Program their eligible family members.
The Non-Foreign Service Personnel and Their Family Members form (DS-6561) is completed by employees of the non-Foreign Affairs agencies and their family members. The information requested on the DS-6561 is required for professional medical staff of the Office of Medical Services to make decisions about the type of medical clearance an employee and his or her 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.
The DS-6561 is available throughout the Department of State via the e-Forms electronic forms application. The form is scanned as an image into the Department’s 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 with the U.S. Coast Guard an EMR program. Estimated completion date is mid-2015.
The information is not duplicated with other collection instruments, with the exception of basic identification and contact information. The medical information collected can routinely change from one clearance exam to the next, as can addresses, agency, type of employment, status of family members, and other information. .
This collection of information does not impact small businesses or other small entities.
Not collecting the required information on the DS-6561 will result in an inability to determine appropriate medical clearances; it will result in increased costs for the medical program; it will not effectively utilize the dollars allocated to the Medical Program; and it will increase costs of medical liability claims, disability claims, and other medical/legal costs associated with the Medical Program. Medical clearances are required throughout an employee’s career overseas.
There are no special circumstances.
A 60-day public notice (8721) was published in the Federal Register on May 7, 2014 in Vol. 79, No. 88. No meaningful public comments were received.
The Department does not make any type or form of payment to the respondent.
Medical records and other medical information associated with 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.
This form requires a Non-Foreign Affairs 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 employee and family members.
The Department of State Office of Medical Services estimates the hour burden of 8,000 hours per year.
The number of respondents per year is approximately 8,000. This
estimate is based upon 40% of approximately 20,000 clearances for
spouses, children, and new non-Foreign Service applicants in FY12.
These forms are required intermittently through each Non-Foreign
Service employee’s career.
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 fees or postage charges to the respondent as the forms image is captured electronically.
14. Total cost to
the Federal Government is $270,400.
The print
cost was determined to be $1,600. This was determined using the cost
of $0.05 per form for printing on a laser printer times 8,000
four-page forms.
The labor cost was estimated
to be $268,800 based on the hour burden of 8,000 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/hour, 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 $270,400.
15. There are no changes
in burden.
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.
This collection does not employ statistical methods in the collection process nor in the use of the information collected.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR |
| Author | USDOS |
| Last Modified By | "%username%" |
| File Modified | 2014-06-27 |
| File Created | 2014-06-27 |