Medical Clearance Update

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-3057 Medical Clearance Update	Form	Modified	Available
Final - Supporting Statement DS3057.docx	Supporting Statement A	Uploaded 2017-05-12	Available
Legal Authorities DS 3057.docx	Supplementary Document	Uploaded 2017-03-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
15003	Medical Clearance Update	Form	Modified

ICR Details

OMB Control No: 1405-0131	ICR Reference No: 201703-1405-001
Status: Historical Active	Previous ICR Reference No: 201402-1405-003
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical Clearance Update
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/16/2017
	Date Received in OIRA: 03/31/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2020	36 Months From Approved	05/31/2017
Responses	16,280	0	16,280
Time Burden (Hours)	8,140	0	8,140
Cost Burden (Dollars)	1,628	0	0

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Abstract: The information requested on the DS-3057 is required for professional medical staff of the Bureau of Medical Services to make decisions on the type of medical clearance an individual and family members are assigned. This medical clearance, in turn, is used by the Foreign Service to determine posts abroad where the Foreign Service member and family may serve.

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

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
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 60400	09/01/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 15093	03/24/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Medical Clearance Update	DS-3057	Medical Clearance Update

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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	16,280	16,280	0	0	0	0
Annual Time Burden (Hours)	8,140	8,140	0	0	0	0
Annual Cost Burden (Dollars)	1,628	0	0	1,628	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:

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Annual Cost to Federal Government: $130,402

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: 03/31/2017

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