Information Collection

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

IC 221440 under ICR 201611-1405-004 · OMB 1405-0224.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0224 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-6570 Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)	Form and Instruction
DS-6570 Employee Self-Certification and Ability to Perform in Em DS-6570.pdf	Form and Instruction

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-6570	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Posts PRE-DEPLOYMENT PHYSICAL EXAM ACKNOWLEDGEMENT FORM	DS-6570.pdf		No		Fillable Fileable

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.