USMS Medical Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CSO-012 CSO-012 Request to Reevaluate Court Security Officer's Medical Qualifications	Form and Instruction	Unchanged	Available
Form USM-600 USM-600 Physical Requirements of USMS District Security Officers	Form and Instruction	Unchanged	Available
Form USM-522P USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	Form and Instruction	Unchanged	Available
Form USM-522A USM-522A Physician Evaluation Report for USMS Operational Employees	Form and Instruction	Unchanged	Repair queued
Memo - USMS.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-03-30	Repair queued
usm522p UPDATED.pdf	Supplementary Document	Uploaded 2017-03-30	Available
SupportingStatement-USMS Medical Forms-2016 Renewal.doc	Supporting Statement A	Uploaded 2016-08-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205746	CSO-012 Request to Reevaluate Court Security Officer's Medical Qualifications	Form and Instruction	Unchanged
205744	USM-600 Physical Requirements of USMS District Security Officers	Form and Instruction	Unchanged
205743	USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	Form and Instruction	Unchanged
205737	USM-522A Physician Evaluation Report for USMS Operational Employees	Form and Instruction	Unchanged

ICR Details

OMB Control No: 1105-0099	ICR Reference No: 201703-1105-001
Status: Historical Active	Previous ICR Reference No: 201605-1105-001
Agency/Subagency: DOJ/LA	Agency Tracking No: USMS-2016-4
Title: USMS Medical Forms
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/04/2017
	Date Received in OIRA: 03/30/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2019	11/30/2019	11/30/2019
Responses	1,112	0	1,112
Time Burden (Hours)	2,882	0	2,882
Cost Burden (Dollars)	152,721	0	152,721

---

Abstract: As a law enforcement agency, the United States Marshals Service has unique medical requirements that prevent USMS from using current medical-related Standard and Optional forms. These forms have been developed to allow USMS to ensure that the applicants, contract employees and current federal employees who work in operational law enforcement positions are physically fit enough to perform their duties safely and successfully.

---

Authorizing Statute(s): US Code: 5 USC 3312 Name of Law: Preference eligibles; physical qualifications; waiver
   EO: EO 9397 Name/Subject of EO: Numbering system for federal accounts relating to individual persons
   US Code: 28 USC 561 Name of Law: United States Marshals Service
   US Code: 28 USC 566 Name of Law: Powers and duties
   US Code: 5 USC 552a Name of Law: Records maintained on individuals
   US Code: 5 USC 3301 Name of Law: Civil service; generally
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 28887	05/10/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 50550	08/01/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
CSO-012 Request to Reevaluate Court Security Officer's Medical Qualifications	CSO-012	Request to Reevaluate Court Security Officer's Medical Qualifications
USM-522A Physician Evaluation Report for USMS Operational Employees	USM-522A	Physician Evaluation Report for USMS Operational Employees
USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	USM-522P	Physician Evaluation Report for USMS Operational Employees - Pregnancy Only
USM-600 Physical Requirements of USMS District Security Officers	USM-600	Physical Requirements of USMS District Security Officers

---

ICR Summary of Burden

table that charts list 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	1,112	1,112	0	0	0	0
Annual Time Burden (Hours)	2,882	2,882	0	0	0	0
Annual Cost Burden (Dollars)	152,721	152,721	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $152,721

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

---

Common Form ICR:  No

---

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: 03/30/2017

---