Final - Supporting Statement DS-6561

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SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION
OMB # 1405-0194, DS-6561

Overseas Pre-Assignment Medical History and Examination
Non-Foreign Service Personnel and Their Family Members

A. JUSTIFICATION

1. Pursuant to the Foreign Service Act of 1980 (22 U.S.C. §§ 3901, 4084) and the Basic Authorities Act of 1956 (22 U.S.C. § 2651), the Secretary has the authority to establish a Medical Program. This information collection provides to the U.S. Department of State’s Office of Medical Services the material needed to determine the appropriate medical clearances for non-Foreign Service personnel who may participate in the Medical Program and their eligible family members.

2. The Overseas Pre-Assignment Medical History and Examination Non-Foreign Service Personnel and Their Family Members form (DS-6561) is completed by employees or contractors of the non-Foreign Affairs agencies and their family members. The information requested on the DS-6561 is required for professional medical staff of the Office of Medical Services to make medical clearance determinations and decisions regarding post of assignment for the employee, or an employee and his or her family members. 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 if medical privacy statutes and regulations do not otherwise protect the information.

3. Presently, the forms are available on the State Department internet site, via www.state.gov. The demographic sections are electronically “fillable” but each individual must provide a paper copy to his or her personal health care provider, and once completed, are scanned and submitted via facsimile or e-mail. 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 the Medical Clearances software application. The Bureau of Medical Services is actively investigating and soliciting product information from commercial EMR products in conjunction with Acquisitions processes. Estimated completion date is mid-2018.

4. The information is generally not duplicated with other collection instruments, with the exception of basic identification and contact information. The medical information collected can routinely change from one clearance exam to the next, as can addresses, agency, type of employment, status of family members, and other information. .

5. This collection of information does not impact small businesses or other small entities.

6. Not collecting the required information on the DS-6561 will result in the inability to appropriately make a medical clearance determination. It would result in assignments of non- Foreign Affairs Agency Federal employees or contractors, and any eligible family members to posts abroad that do not have adequate medical facilities and resources to treat their underlying medical conditions. The current requirement for a medical clearance is for the length of assignment, or every 2 years, whichever is shorter. After the initial DS-6561, individuals can optionally use the shorter Medical Clearance Update Form DS -3057. This frequency serves the Department and respondents well and obtains the required information at the time that it is needed and not before.

7. There are no circumstances that would require the information to be collected in the manner described in the instructions for the supporting statement.

8. The 60-day notice published in the Federal Register on 3/27/2017 (82 FR 15267) and elicited no public comments.

9. The Department does not make any type or form of payment to the respondent.

10. Medical records and other medical information associated with a particular individual are governed under the Privacy Act of 1974, 5 U.S.C. § 552a. 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.

11. This form requires a Non-Foreign Affairs employee or family member to provide information regarding chronic medical conditions, mental health status, and past mental health treatment. 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.

12. The Department of State Bureau of Medical Services estimates the hour burden of 9,890 hours per year.
    
    The number of respondents per year is approximately 9,890. This number is based on data collection of all DS-6561 forms processed by medical records in FY 2015 for non-Foreign Service applicants. These forms are required intermittently through each Non-Foreign Service employee’s career.
    
    The annual burden was estimated based upon the number of respondents and an estimate of one hour to gather the information, transcribe the information, print and sign the form, and send it to Medical Clearances.

The hour burden cost was estimated to be $ 653,630.10 based on the hour burden of 9,890 hours x $66.09 hour.  This was determined using the U.S. Department of Labor, Bureau of Labor Statistics website (www.bls.gov), the average mean hourly wage for a nurse practitioner is $47.21/hr., multiplied by 1.4 for a weighted hourly wage of $66.09

13. There is no cost to respondents.

14. Total cost to the Federal Government is $159,525.70

The printing cost, $0.05 per page (9,890 x 4 pages per response) is $1,978.00.

The scanning cost to process the form into our Electronic Medical Record System is estimated at $3.17 per form for a total of $31,351.30 per year. The cost of processing the form is estimated at $12.76 per form multiplied by 9890 forms or $126,196.40 per year.

Adding all costs together for the printing, scanning and processing, and labor, the total cost is therefore $159,525.70.

15. There was an increase in respondents seeking medical clearance to overseas assignment, from 8,000 at last form renewal date to 9890 in 2016. As for form DS-6561, it was updated throughout to clarify the title and purpose. Changes to DS-6561 include: demographic collection changes to improve identification of employee agency or contracting group and assignment information; the instructions on submission were revised and updated. Medical history questions were revised to include common cancer screening testing; mental health, substance abuse and educational questions were revised; high threat/unaccompanied post/PTSD questions removed; Privacy Act Notice updated to include authorities, purpose, routine uses and disclosure; and Genetic Information Nondiscrimination Act (GINA) guidance was amended to include notice to individual completing form.

16. The Department will not publish the results of this collection.

17. The Department will display the expiration date for OMB approval of the information collection.

18. There are no exceptions to the certification statement.

B. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS

This collection does not employ statistical methods in the collection process nor in the use of the information collected.