Final - 30 Day ESCAPE Form Supporting Statement

SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION

Self Certification and Ability to Perform in Emergencies (ESCAPE)
OMB Number 1405- 0224
DS-6570

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 et seq.), the Secretary has the ability to establish a medical program. Also, 22 U.S.C. 4084 provides authority to establish a Health Care Program. 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 Self Certification and Ability to Perform in Emergencies (ESCAPE) posts and are capable of performing certain emergency safety functions.

ESCAPE posts comprise a subset of High-Threat/High Risk (HTHR) posts in areas of conflict where there is an increased likelihood that personnel may be required to wear personal protective equipment (PPE); utilize non-standard modes of transportation such as high-axle armored vehicles and helicopters; react unassisted to direct or indirect fire over uneven terrain, including stairs; and react to incidents involving fire as a weapon. The purpose of designating a post as an ESCAPE post is to recognize the potentially extreme and life-threatening conditions at these posts, to ensure that non-federal individuals seeking assignment under Chief of Mission authority to an ESCAPE post are aware of the unique conditions at these posts, and to require that they be able to perform certain emergency functions.

Authorities also include:

1. System of records Notice State-24, Medical Records
   https://foia.state.gov/_docs/SORN/State-24.pdf

2. Privacy Act of 1974. http://www.justice.gov/opcl/privstat.htm

3. Title 5 U.S.C. 552A. https://www.gpo.gov/fdsys/pkg/USCODE-2013-title5/pdf/USCODE-2013-title5-partI-chap5-subchapII-sec552a.pdf

2. The information requested on DS-6570 is required for Department of State professional medical staff of the Office of Medical Services to make appropriate medical clearance decisions. The information on DS-6570 is collected during the medical review between the employee and his/her medical provider. The employee will submit the completed form, signed by both the employee and provider, to the Bureau of Medical Services at the U.S. Department of State.

3. The DS-6570 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.

4. Information is not duplicated with other collection instruments, with the exception of basic identification information. Medical information required will routinely change from one deployment to another and using the DS-6570, ESCAPE will affirm that employees understand the physical rigors and security conditions at post and can perform specified emergency functions.

5. This information collection does not significantly impact small businesses or other small entities. Some contractors' employees might not be able to deploy to these posts.

6. Without this information, State would not be able to determine and obtain an optimal level of qualified employees and contractors for posts that require high level of ability and State want to be certain individuals are able to perform certain emergency functions as a prerequisite to assignment to an ESCAPE post.

7. There are no special circumstances.

8. A 30-day notice will be published in the Federal Register to elicit public comments. There was a 60-day notice published in the Federal Register on September 9, 2016 (81 FR 62547) and there were no comments received during the 60-day comment period.

9. There are no payments or gifts given to the respondents.

10. There are no promises of confidentiality made to the respondents.

11. This form requires an employee's or contractor's medical provider to provide information regarding the individual’s medical condition that is required before being deployed under the ESCAPE program. These questions are necessary to gauge the employee’s or contractor's ability to be assigned to High Risk/High Threat posts. The posts that require high level of ability want to be certain that employees and contractors are able to perform certain emergency functions.

12. The Department of State, Bureau of Medical Services estimates the hour burden of 100 annual hours per year. This number is determined by 200 respondents X 30(minutes to complete form) /60 minutes = 100 annual hours.

The hour burden cost was estimated to be $6,609 cost to respondents completing the form based on the hour burden of 100 hours x $66.09 hour. This was determined using the U.S. Department of Labor, Bureau of Labor Statistics website (www.bls.gov). The average mean hourly wage for a nurse practitioner is $47.21/hr., multiplied by 1.4 for a weighted hourly wage of $66.09.

13. There is no cost to respondents.

14. There is no cost to the Federal Government.
    
    
    
    

15. There are no changes to the program. However, there have been changes made to the form and they are as follows:

• In question #13, the word "Symptomatic" was deleted.

• In question #15, "Myocardial infarction" was changed to "Heart attack."
  
  

16. The Department will not publish the results of this collection.

17. The Department will display the expiration date for OMB approval of the information collection.

18. There are no exceptions to the certification statement.

B. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS

This collection does not employ statistical methods.