SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION
OMB # 1405-0131,
DS-3057
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), the Secretary has the ability to establish a medical program. As specified in 16 FAM 220, paragraph b, the medical program provides medical examinations for applicants for employment and also medical examinations as necessary for members of the Foreign Service and employees of the Department and their eligible family members . The Medical Clearance Program ensures that all members of the Foreign Service, other Department employees, other Agency employees through the ICASS program, and their family members have appropriate medical facilities abroad for any underlying medical conditions.
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. The information collected is not directly released to any other Federal, State, or local agency. During security investigations certain aspects of the information collected may be released to the investigating agency once a certified need is determined and medical privacy statutes and regulations do not otherwise protect the information.
The DS-3057 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. The Bureau of Medical Services is actively developing an EMR program.
Although information may appear to be duplicated with other collection instruments, it generally is not, with the exception of basic identification and contact information. Addresses, agency, type of employment, and other information can routinely change during the periods between the medical clearance update. Family members in particular may change status, type of employment, and other information that is collected. Medical information required will routinely change from medical clearance update to update. Use of the DS-3057 Medical Clearance Update form allows comparison of salient health conditions from one clearance update to another without necessitating a physical examination.
This collection of information does not impact small businesses or other small entities.
Not collecting the required information on the DS-3057 will result in assignments of Foreign Service Officers, Federal employees, and their families to posts abroad that do not have adequate medical facilities to treat their underlying medical conditions. It will result in increased costs for the medical program; will not effectively utilize the dollars allocated to the Medical Program; and will increase costs of medical liability claims, disability claims, and other medical/legal costs associated with the Medical Program. The current requirement for a medical clearance is between post assignments or every three years, whichever is longer. This frequency serves the Department well and obtains the required information at the time that it is needed and not before.
There are no circumstances that would require the information to be collected in the manner described in the instructions for the supporting statement.
A 60-day notice was published in the Federal Register (81 FR 60400); no comments were received.
The Department does not make any type or form of payment to the respondent.
Medical records and other medical information identified to a particular individual are governed under the Privacy Act of 1974. The Bureau of Medical Services is authorized to collect this health information pursuant to section 904 of the Foreign Service Act, 22 U.S.C. § 4084. With the Privacy Act Statement included, there is further assurance of confidentiality as governed by Title 5 U.S.C. 552A.
This form requires a Foreign Service Officer, Federal employee or family member to provide information regarding mental health status, past mental health treatment, and chronic medical conditions. Although not routinely discussed, except with a person’s health care provider, these questions are necessary to gauge the individual and family members’ ability to be assigned to hardship posts, or posts where medical resources are scarce. The form also requires a discussion regarding any special educational needs that a dependent child may have. This too would preclude some posts for consideration for overseas assignment.
The Department of State Bureau of Medical Services estimates the hour burden of 8,140 hours per year for respondents to gather the information. The number was determined by 16,280 respondents X 30(minutes to complete form) /60 minutes = 8,140 annual hours.
The hour burden cost was estimated to be $264,713 based on the hour burden of 8,140 hours x $32.52/hour. Using the U.S. Department of Labor, Bureau of Labor Statistics website (www.bls.gov) “all occupation” average mean hourly of $23.23 x 1.4 for a weighted hourly wage of $32.52.
The cost to respondents for them to print two pages at $0.05 totals $1,628 (16,280 x $.10 (2pgs).
14. Total cost to the Federal Government is $130,402.80.
The Printing cost, ($0.05 per page) for 32,560 pages (16,280 x 2 pages per response) is $1,628.00.
The scanning cost to process the form into our Electronic Medical Records System is estimated at $1.53 per form for a total of $24,908.40. The cost of processing the form is estimated at $6.38 per form multiplied by 16,280 or $103,866.40 per year
Adding all costs together for the printing, scanning and processing, and labor, the total cost is therefore $130,402.80.
15. During this renewal cycle, a correction was made to the Federal Government costs that was corrected to $0 therefore from the last submission, there should not have been a cost associated to the Federal Government. As for the form, DS-3057 was updated to improve demographic collection; employee agency and assignment information. Changes also included; instructions on submission were revised and updated; medical history questions were revised to include current medications; high threat/unaccompanied post questions removed; and Privacy Act Notice updated and Genetic Information Nondiscrimination Act (GINA) guidance added.
16. The information collected will not be published or routinely tabulated. The only tabulation that is required is the total number of clearances issued.
17. The Bureau of Medical Services will display the expiration date on the form.
18. The Department is not seeking exceptions to the certification statement.
This collection does not employ statistical methods in the collection process nor in the use of the information collected.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SUPPORTING STATEMENT FOR |
| Author | USDOS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |