Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-6570 Pre-Deployment Physical Exam Acknowledgement Form	Form and Instruction	Modified	Available
Form DS-6570 Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)	Form and Instruction	Modified	Repair queued
Legal Authorities 1405-0224 (DS-6570).docx	Supplementary Document	Uploaded 2022-09-27	Repair queued
Supporting Statement 1405-0224 (DS-6570) 30day.docx	Supporting Statement A	Uploaded 2022-09-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
221440	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)	Form and Instruction	Modified	Pre-Deployment Physical Exam Acknowledgement Form
221440	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)	Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0224	ICR Reference No: 202209-1405-002
Status: Active	Previous ICR Reference No: 202001-1405-002
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/31/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/27/2022
Terms of Clearance: Upon resubmission, the agency will ensure it is uploading a PDF version of the form and does not upload an FAR version.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2026	36 Months From Approved	08/31/2023
Responses	532	0	532
Time Burden (Hours)	532	0	532
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose for soliciting this information is to make appropriate medical clearance decisions that better assess potential bidders that are capable of the unique, potentially challenging and life-threatening conditions at Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) posts and are capable of performing certain emergency safety functions.

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Authorizing Statute(s): US Code: 22 USC 3901 Name of Law: the Foreign Service Act of 1980
  

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:
	87 FR 11782	07/11/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 11870	09/27/2022
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
Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)	DS-6570	Pre-Deployment Physical Exam Acknowledgement Form

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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	532	532	0	0	0	0
Annual Time Burden (Hours)	532	532	0	0	0	0
Annual Cost Burden (Dollars)	0	0	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:

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Annual Cost to Federal Government: $8,022

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? No

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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: 09/27/2022

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