0596-0164 Supporting Statement A_v03302016

2015 Supporting Statement for OMB 0596-0164 and

FIRE AND AVIATION MANAGEMENT MEDICAL QUALIFICATIONS PROGRAM

NOTE: This collection was formally titled Health Screening Questionnaire. Forest Service changed

the title to better reflect information collected.

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 (FS) to fight fires on National Forest System (NFS) 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 and health to avoid injury to themselves or their coworkers.

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.

The Forest Service and Department of the Interior wildland fire management agencies use a Work Capacity Test (WCT) Informed Consent and 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 applicants and employees are subjected to arduous physical fitness tests. Use of the HSQ allows for health screening to occur without every applicant or employee having to submit to a medical examination.

Title 5 CFR, Part 339, Medical Qualification Determinations, authorizes the FS to establish medical qualification standards and require pre-appointment medical examinations, regular recurring periodic examinations after appointment, and whenever there is a direct question about a firefighter’s continued ability to meet the medical qualification standards. This applies only to anyone in the FS fire community with an arduous duty fitness qualification.

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.)

Medical history information regarding the health and fitness of applicants for wildland firefighter or non-primary fire staff positions will be collected.

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 and employees for wildland firefighter or non-primary fire staff positions; all personnel seeking to complete a Work Capacity Test (WCT) for the purposes of employment as a wildland firefighter or non-primary fire staff are required to complete the forms.

Table 1

Information Collected	Description	Information Provided to:	Prepared by
Consent for testing	Work Capacity Test Informed Consent FS-5100-30	Unit employing wildland firefighter or non-primary fire staff	Non-federal employee applicants and federal employees for Wildland Firefighter positions and non-primary fire staff
Focused medical history	Health Screening Questionnaire (HSQ) FS-5100-31
Medical history and exam	Wildland Firefighter Medical Qualifications Program Medical Exam FS-5100-32 - New	Medical Officer	Non-federal employee applicants and federal employees for Wildland Firefighter positions and medical provider
Medical history and blood pressure	Self-Certification Statement and Blood Pressure Check FS-5100-33 - New

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

This information will be used to determine medical 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 e-forms that will be available on the FS Internet website. The applicant/employee and medical providers fill out the forms on-line, electronically sign, and the submit button will automatically send the form to the appropriate government official that will review the form. Printed and signed forms may be scanned and sent electronically by email or faxed to a secure fax.

FS-5100-31 – Health Screening Questionnaire (HSQ) and FS-5100-30 – Work Capacity Test (WCT) Informed Consent - The collection of this information is necessary to ensure whether an individual (not currently an employee of the Federal government) who is being considered for a wildland firefighter position or non-primary fire staff 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.

FS-5100-32 – Wildland Firefighter Medical Qualifications Program (MQP) and FS-5100-33 Medical Exam, Self-Certification Statement and Blood Pressure (BP) Check – The collection of this information is necessary to ensure whether an individual (not currently an employee of the Federal government) who is being considered for a wildland firefighter position is medically qualified to participate in fighting fire, meeting the established medical qualification standards, so as not to pose an undue risk to themselves or their coworkers. These new forms will replace the use of OF-178.

4. How frequently will the information be collected?

The information will be collected from individual applicants/employees seeking wildland firefighting or non-primary fire staff positions once a year prior to taking the WCT. The HSQ will be completed yearly for those firefighters that are not yet enrolled in the Medical Qualification Program (MQP) as it is being implemented. The Wildland Firefighter MQP Medical Exam will be filled out every three years by firefighters. The intervening two years between these exams, the firefighters will fill out a Self-Certification Statement and BP Check yearly. The WCT Informed Consent is filled out yearly before taking the WCT.

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

The information collected will reside in the applicants’/employees’ electronic medical file and will be maintained and shared according to provisions outlined in the Privacy Act.

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

The requirements for the HSQ and WCT Informed Consent have not changed over time. These forms have been used for this purpose for the last 15 years.

An Interagency Medical Standards Program had been instituted in the past with poor success in regards to the contractor used. That program had regular recurring medical exams for firefighters. This new program will not be using a contractor and the new Wildland Firefighter MQP Medical Exam for arduous duties will take the place of the OF-178 currently used for those who must complete a medical exam. The medical exam will be obtained every three years and the new Self-Certification Statement and BP Check will be taken yearly the two intervening years. These are two new forms.

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.

Applicants/employees may access the forms via the FS Internet website, where they may fill out the form on-line submitting it electronically, or they may print out the form, complete it, sign and mail, or scan and email, or fax the form if needed.

The need for creating electronic medical records for the Medical Qualifications workflow has been acknowledged, so that we can decrease the paper burden and create a smoother workflow in this process. Overall the intent is to make the system easier to use and more timely for field personnel including firefighters and fire managers. The medical industry in the U.S. is making an intentional shift to electronic medical record keeping. Given the sheer amount of data generated by the HSQ and ultimately the Wildland Firefighter MQP Medical Exam for the arduous duty wildland firefighters under the MQP, it only makes sense for the Forest Service to take this approach to medical recordkeeping as well. This will decrease the paper burden that is currently created, create a smoother workflow as well as create easier access to needed information by those who will have ‘need to know’ access only, such as the HSQ coordinators, the dedicated MQP Assistant, and medical officers.

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.

If the applicant brings up the fact that he/she had a medical exam in the last 3-4 months and wants to provide that information, it will be reviewed, and what was not evaluated that is required on the Wildland Firefighter MQP Medical Exam, will be requested to be obtained.

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

If the applicant brings up the fact that he/she had a medical exam in the last 3-4 months and wants to provide that information, it will be reviewed, and what was not evaluated that is required on the Wildland Firefighter MQP Medical Exam, will be requested to be obtained.

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 WCT, potential applicants submit a signed copy of the WCT Informed Consent to show that they understand the risks involved in participating in the WCT.

In order to show that they are medically fit enough to pass the WCT, potential applicants must provide the information requested on the HSQ, the Wildland Firefighter MQP Medical Exam, or the Self-Certification Statement and BP Check.

Wildland firefighting is seasonal. The information is requested yearly at the time the FS hires new employees for these duties. This information collection request only covers members of the public not currently employed by the FS who are applying for employment as wildland firefighters or non-primary fire staff.

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 medical 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 WCT Informed Consent, HSQ, Wildland Firefighter MQP Medical Exam and Self-Certification Statement, and BP Check forms, as indicated, 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 needs for emergency wildland firefighters or non-primary fire staff.

• 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 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 Notice was published on January 6, 2016 (Federal Register, Vol. 81, No. 3, Page 459). FS received one comment from the public in response to this Federal Register notice, but it was not regarding the Paperwork Reduction Act.

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.

• Wayne Ching, Fire Management Officer, Hawaii Division of Forestry & Wildlife

  • Phone: 808-587-4173

• Matt Bowers, Smokejumper, Bureau of Land Management

  • Phone: 208-387-5426

• L. Kaili McCray, DOI, Medical Standards Program Manager, Department of Interior

  • Phone: 208-387-5810

Consultation included discussion with the individuals noted above. The instructions are clear and frequency of collection noted above is not an unreasonable burden. The questions asked are not out of the ordinary and are reasonable. Compilation and recordkeeping of collected data is completed in accordance to privacy regulations.

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), electronic records are protected by restricted access procedures and audit trails. Access to records is strictly limited to agency officials with a bona fide need for the records.

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 information that is collected only includes applicant medical and personal fitness information that is directly related to the physical demands of a wildland firefighting or non-primary fire staff position prior to the administration of a physical fitness test. Collection of this information assists the Government to determine if an applicant is medically suited to take the WCT. For potential wildland firefighter applicants, taking and passing the WCT 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.

This submission has 34,950 respondents for an increase of 22,320 respondents; 89,520 responses for an increase of 64,260 responses and 10,289 hours for an increase of 8,192 hours.

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. If this request for approval covers more than one form, provide separate hour burden estimates for each form.

a) Description of the collection activity

b) Corresponding form number (if applicable)

c) Number of respondents

d) Number of responses annually per respondent,

e) Total annual responses (columns c x d)

f) Estimated hours per response

g) Total annual burden hours (columns e x f)

Table 2

(a) Description of the Collection Activity	(b) Form Number	(c) Number of Respondents	(d) Number of Responses Annually per Respondent	(e) Total Annual Responses (c x d)	(f) Estimate of Burden Hours per Response	(g) Total Annual Burden Hours (e x f)
Work Capacity Test Informed Consent*	FS-5100-30	20,271 (FS)	1	20,271	5.5 minutes (0.09 hours)	1,824
		14,679 (DOI)	1	14,679		1,321
Health Screening Questionnaire*	FS-5100-31	20,271 (FS)	1	20,271	3 minutes (0.05 hours)	1,014
		14,679 (DOI)	1	14,679		734
Wildland Firefighter Medical Qualifications Program Medical Exam**	FS-5100-32	9,810 (FS)	1	9,810	30 minutes (0.5 hours)	4,905
Self-Certification Statement and Blood Pressure Check**	FS-5100-33	9,810 (FS)	1	9,810	3 minutes (0.05 hours)	491
Totals	---	34,950	---	89,520	---	10,289

*These totals were calculated by querying the Incident Qualifications and Certification System (IQCS), the interagency training and qualification database of record for 2013, the most recent year complete records are available; showing how many wildland firefighting candidates and non-primary fire staff completed the FS-5100-30 and FS-5100-31 forms in order to obtain clearance for the WCT. The estimate of Burden hours per response was obtained by averaging the time it took for a sample group of people to actually read and fill out the forms.

**These totals were calculated by querying the Incident Qualifications and Certification System (IQCS), the interagency training and qualification database of record for 2013, the most recent year complete records are available; showing how many wildland firefighting candidates completed the FS-5100-30 and FS-5100-31 forms in order to obtain clearance for the WCT. In any given year about half will complete a Wildland Firefighter MQP Medical Exam and half the Self-Certification Statement and BP Check. The estimate of Burden hours per response was obtained by averaging the time it took for a sample group of people to actually read and fill out the forms.

• Record keeping burden should be addressed separately and should include columns for:

a) Description of record keeping activity:

b) Number of record keepers:

c) Annual hours per record keeper:

d) Total annual record keeping hours (columns b x c):

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories.

Table 3

(a) Description of the Collection Activity	(b) Estimated Total Annual Burden on Respondents (Hours)	(c) Estimated Average Income per Hour	(d) Estimated Cost to Respondents (b x c)
Work Capacity Test – Informed Consent	3,145	$17.80	$55,981
Health Screening Questionnaire	1,748	$17.80	$31,114
Wildland Firefighter MQP Medical Exam	4,905	$17.80	$87,309
Self-Certification Statement and Blood Pressure Check	491	$17.80	$ 8,740
Totals	10,289	---	$183,144.00

Estimated Income Source: Bureau of Labor Statistics Category 19-4093, Forest and Conservation Technicians (Forest and Conservation Technicians). The Health Screening Questionnaire numbers will decrease once the Medical Exam and Self-Certification Statement and Blood Pressure Check are instituted.

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.

No capital startup or maintenance cost.

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 application vendor was solicited for fixed price development and support costs based on requirements developed by the project team. In addition, a top down approach was used to estimate the additional contractor and support cost.

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

508 Compliance: $25,000

Assessment & Authorization (Security): $45,000

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

• Employee travel costs

$25,000 estimated

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

Vendor (GDCII) program support costs: $50,000

Vendor (GDCII) license and O&M costs Year 1: $165,000

Vendor (GDCII) ongoing O&M and program support post FY2015: $265,000 annually

• Employee labor and materials for collecting the information

Implementation costs: $247,000

• 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 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 4

ACTION ITEM	PERSONNEL	GS LEVEL	HOURLY RATE*	HOURS	SALARY
Staff hours to review applications		7	$16.28	2,096	$34,123
Personnel Analyst hours to assure form is part of hiring package		11	$24.10	2,096	$50,514
Program Analyst hours to serve as the lead for contract, budget, 508 Compliance, A&A, IRDB, CPIC and Person Model Oversight and Management		12	$33.06	2,096	$71, 022
Totals	-	-	-	6288	$152,959

15. Explain the reasons for any program changes or adjustments reported in items 13 or 14 of OMB form 83-I.

This submission reflects a program change increase of 19,620 responses and 5,396 burden hours for new forms FS-5100-32 and FS-5100-33 which replace the OF-178. The remaining adjustment increase of 44,640 responses and 2,796 hours is due to an increase in respondents and, for safety reasons, FS will be increasing the number of medical qualification exams done annually. With the approval of the Wildland Firefighter MQP Medical Exam and Self-Certification Statement and BP Check forms, the new MQP is going to be implemented for anyone seeking an arduous duty fitness qualification with the FS. Once fully implemented, those seeking an arduous duty red card with the FS will no longer complete the HSQ. Only those seeking light or moderate duty will complete the HSQ at that point on.

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 FS is able to certify compliance with all provisions under item 19 of OMB 83-I.