AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
1123-0NEW Supporting Statement Medical ARI-Mental Health.11.16.23.docx	Supporting Statement A	Uploaded 2023-12-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
263824	RELEASE OF MEDICAL INFORMATION		New

ICR Details

OMB Control No:	ICR Reference No: 202312-1123-003
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOJ/CD	Agency Tracking No:
Title: AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 12/07/2023

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	1,000	0
Time Burden (Hours)	83	0
Cost Burden (Dollars)	441	0

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Abstract: The information collected from the Authorizations for the Release of Medical Information will primarily be used to make recommendations regarding executive clemency and ensure proper notification to the Federal Bureau of Investigation, U.S. Attorneys’ Offices, U.S. Probation Offices, and federal courts in the event of grants of executive clemency. The Authorization for the Release of Medical Information will only be collected once per application for clemency. If the collection is not conducted, the Pardon Attorney cannot fulfill its directive to receive, investigate, and facilitate the disposition of applications for executive clemency. This would prevent the Pardon Attorney from completing its vital mission to assist the President in executing his acts of executive clemency. The Office of the Pardon Attorney has authority to collect this information under the United States Constitution, Article II, Section 2 (the pardon clause); Orders of the Attorney General Nos. 1798-93, 58 Fed. Reg. 53658 and 53659 (1993), 2317-2000, 65 Fed. Reg. 48381 (2000), and 2323-2000, 65 Fed. Reg. 58223 and 58224 (2000), codified in 28 C.F.R. §§ 1.1 et seq. (the rules governing petitions for executive clemency); and Order of the Attorney General No. 1012-83, 48 Fed. Reg. 22290 (1983), as codified in 28 C.F.R. §§ 0.35 and 0.36 (the authority of the Office of the Pardon Attorney).

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Authorizing Statute(s): None

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:
	88 FR 66900	09/28/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 83965	12/01/2023
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
RELEASE OF MEDICAL INFORMATION

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	1,000	0	0	1,000	0	0
Annual Time Burden (Hours)	83	0	0	83	0	0
Annual Cost Burden (Dollars)	441	0	0	441	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection

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Annual Cost to Federal Government: $21,420

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: 12/07/2023

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