Application for Civil Surgeon Designation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form I-910 Application for Civil Surgeon Designation	Form	Modified	Available
I-910-Supporting Statement-Fee Rule-NPRM-83C.docx	Supporting Statement A	Uploaded 2019-11-14	Available
I910-INS-TOC-2019FeeRule-10302019.docx	Supplementary Document	Uploaded 2019-11-07	Repair queued
I-910 83C.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2019-11-07	Available
privacy-pia-uscis-067-civilsurgeon-june1,2017.pdf	Supplementary Document	Uploaded 2018-04-10	Available
privacy-pia-064-uscis-myuscis-dec14,2016.pdf	Supplementary Document	Uploaded 2018-04-10	Available
SORN 007 Benefits Info Sys 2016 10 19.pdf	Supplementary Document	Uploaded 2018-04-10	Available
Reference_Citations[1].doc	Supplementary Document	Uploaded 2015-10-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
192797	Application for Civil Surgeon Designation	Form	Modified

ICR Details

OMB Control No: 1615-0114	ICR Reference No: 201911-1615-018
Status: Historical Inactive	Previous ICR Reference No: 201804-1615-001
Agency/Subagency: DHS/USCIS	Agency Tracking No: I-910
Title: Application for Civil Surgeon Designation
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OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 12/21/2019
	Date Received in OIRA: 11/27/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2020	05/31/2020	07/31/2020
Responses	538	0	538
Time Burden (Hours)	1,076	0	1,076
Cost Burden (Dollars)	26,459	0	26,459

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Abstract: This information collection is required to determine whether a physician meets the statutory and regulatory requirement for civil surgeon designation.

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Authorizing Statute(s): US Code: 8 USC 1182 Name of Law: U.S. Code
  

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:
	83 FR 2815	01/19/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 15395	04/10/2018
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
Application for Civil Surgeon Designation	I-910	Application for Civil Surgeon Designation

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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: $422,330

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 11/27/2019

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