Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)

Forms and Documents

Document Name	Status
Form DS-6570 Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Form and Instruction	New
MED Supporting Statement - Final.docx Supporting Statement A	2016-05-10
DS-6570 Memo 5-2-16.pdf Supplementary Document	2016-05-10
MED Justification emergreview.docx Supplementary Document	2016-05-10
MED Legal Authorities.docx Supplementary Document	2016-05-10

IC Document Collections

IC ID	Document Title	Status
221440	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Form and Instruction	New

ICR Details

OMB Control No: 1405-0224	ICR Reference No: 201605-1405-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 05/23/2016
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/24/2016
	Date Received in OIRA: 05/10/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2016	6 Months From Approved
Responses	200	0	0
Time Burden (Hours)	100	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose for soliciting this information is to make appropriate medical clearance decisions that better assess potential bidders that are capable of the unique, potentially challenging and life-threatening conditions at Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) posts and are capable of performing certain emergency safety functions.

Emergency Justfication: The goal of the “Employee Self Certification and Ability To Perform In Emergencies” (ESCAPE) program is to ensure that non-federal individuals who are seeking a contracted position at a designated post are capable of the unique, potentially challenging and life-threatening conditions at ESCAPE posts and are capable of performing certain emergency safety functions. Individuals are required to review with a medical provider the pre-deployment acknowledgement form and then affirm that they understand the physical rigors and security conditions at these posts and can perform any specified emergency functions. A working group at the State Department has developed this program at the direction of the Under Secretary for Management (M). In the past, a number of individuals have not been able to successfully complete their assignments to these posts because of limiting medical or physical limitations that were not identified before deployment. These limiting conditions put not only these individuals at risk but also post personnel and property. ESCAPE posts are located in Afghanistan, Iraq, Libya, and Yemen. There is a need for an emergency review and approval before the next group of individuals are deployed to these posts in June, 2016 to ensure all can perform their responsibilities.

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Authorizing Statute(s): US Code: 22 USC 3901 Name of Law: the Foreign Service Act of 1980
  

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

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
Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)	DS-6570	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Posts PRE-DEPLOYMENT PHYSICAL EXAM ACKNOWLEDGEMENT FORM

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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	200	0	0	200	0	0
Annual Time Burden (Hours)	100	0	0	100	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: This is a new collection.

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Annual Cost to Federal Government: $0

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: 05/10/2016

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