USMS Medical Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSO-012 Request to Reevaluate Special Security Officer's Medical Qualifications	Form and Instruction	New	Available
Form SSO-012 SSO-012 Request to Reevaluate Special Security Officer's Medical Qualifications	Form and Instruction	New	Repair queued
Form USM-602 Contract Guard Physical Examination Report	Form and Instruction	Modified	Repair queued
Form USM-602 USM-602 Contract Guard Physical Examination Report	Form and Instruction	Modified	Repair queued
Form OMB #1105-0099 Request to Reevaluate Court Security Officer's Medical Qualification	Form and Instruction	Modified	Repair queued
Form CSO-012 Request to Reevaluate Court Security Officer's Medical Qualification	Form and Instruction	Modified	Repair queued
Form CSO-012 CSO-012 Request to Reevaluate Court Security Officer's Medical Qualifications	Form and Instruction	Modified	Repair queued
Form USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	Form and Instruction	Unchanged	Repair queued
Form USM-522P USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	Form and Instruction	Unchanged	Repair queued
Form USM-522A Physician Evaluation Report for USMS Operational Employees	Form and Instruction	Unchanged	Repair queued
Form USM-522A USM-522A Physician Evaluation Report for USMS Operational Employees	Form and Instruction	Unchanged	Repair queued
All Except OVW - April ICRs Approved.pdf	Supplementary Document	Uploaded 2025-07-21	Repair queued
1105-0099-Description of Proposed Changes_20250708.docx	Supplementary Document	Uploaded 2025-07-08	Repair queued
USM-600 - USMS Security Officer Physical Requirements - Replaced by USM-602 Form.pdf	Supplementary Document	Uploaded 2025-07-08	Repair queued
1105-0099-Description of Proposed Changes.docx	Supplementary Document	Uploaded 2020-01-10	Missing upstream
usm600-20180104.pdf	Supplementary Document	Uploaded 2018-01-04	Repair queued
1105-0099 Changes - 2017 - Justification.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2018-01-04	Repair queued
Memo - USMS.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-03-30	Available
usm522p UPDATED.pdf	Supplementary Document	Uploaded 2017-03-30	Repair queued
1105-0099-Supporting Statement-2025 Renewal.docx	Supporting Statement A	Uploaded 2025-07-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
269391	SSO-012 Request to Reevaluate Special Security Officer's Medical Qualifications	Form and Instruction	New	Request to Reevaluate Special Security Officer's Medical Qualifications
269391	SSO-012 Request to Reevaluate Special Security Officer's Medical Qualifications	Form and Instruction	New
229431	USM-602 Contract Guard Physical Examination Report	Form and Instruction	Modified	Contract Guard Physical Examination Report
229431	USM-602 Contract Guard Physical Examination Report	Form and Instruction	Modified
205746	CSO-012 Request to Reevaluate Court Security Officer's Medical Qualifications	Form and Instruction	Modified	Request to Reevaluate Court Security Officer's Medical Qualification
205746	CSO-012 Request to Reevaluate Court Security Officer's Medical Qualifications	Form and Instruction	Modified	Request to Reevaluate Court Security Officer's Medical Qualification
205746	CSO-012 Request to Reevaluate Court Security Officer's Medical Qualifications	Form and Instruction	Modified
205743	USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	Form and Instruction	Unchanged	Physician Evaluation Report for USMS Operational Employees - Pregnancy Only
205743	USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	Form and Instruction	Unchanged
205737	USM-522A Physician Evaluation Report for USMS Operational Employees	Form and Instruction	Unchanged	Physician Evaluation Report for USMS Operational Employees
205737	USM-522A Physician Evaluation Report for USMS Operational Employees	Form and Instruction	Unchanged

ICR Details

OMB Control No: 1105-0099	ICR Reference No: 202406-1105-004
Status: Active	Previous ICR Reference No: 201911-1105-001
Agency/Subagency: DOJ/LA	Agency Tracking No: 1105-0099
Title: USMS Medical Forms
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/30/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/21/2025
Terms of Clearance: In accordance with 5 CFR 1320, this information collection is approved

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2029	36 Months From Approved
Responses	1,139	0	0
Time Burden (Hours)	2,783	0	0
Cost Burden (Dollars)	157,014	0	0

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Abstract: As a law enforcement agency, the United States Marshals Service has unique medical requirements that prevent USMS from using current medical-related Standard and Optional forms. These forms have been developed to allow USMS to ensure that the applicants, contract employees and current federal employees who work in operational law enforcement positions are physically fit enough to perform their duties safely and successfully.

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Authorizing Statute(s): EO: EO 9397 Name/Subject of EO: Numbering system for federal accounts relating to individual persons
   US Code: 28 USC 566 Name of Law: Powers and duties
   US Code: 5 USC 3301 Name of Law: Civil service; generally
   US Code: 5 USC 3312 Name of Law: Preference eligibles; physical qualifications; waiver
   US Code: 5 USC 552a Name of Law: Records maintained on individuals
   US Code: 28 USC 561 Name of Law: United States Marshals Service
  

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:
	90 FR 18868	05/02/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 30100	07/08/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
CSO-012 Request to Reevaluate Court Security Officer's Medical Qualifications	CSO-012, OMB #1105-0099	Request to Reevaluate Court Security Officer's Medical Qualification ,   Request to Reevaluate Court Security Officer's Medical Qualification
SSO-012 Request to Reevaluate Special Security Officer's Medical Qualifications	SSO-012	Request to Reevaluate Special Security Officer's Medical Qualifications
USM-522A Physician Evaluation Report for USMS Operational Employees	USM-522A	Physician Evaluation Report for USMS Operational Employees
USM-522P Physician Evaluation Report for USMS Operational Employees - Pregnancy Only	USM-522P	Physician Evaluation Report for USMS Operational Employees - Pregnancy Only
USM-602 Contract Guard Physical Examination Report	USM-602	Contract Guard Physical Examination Report

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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	1,139	0	0	27	0	1,112
Annual Time Burden (Hours)	2,783	0	0	68	0	2,715
Annual Cost Burden (Dollars)	157,014	0	0	4,293	0	152,721

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: The SSO-012 form is a new form that was added to the USMS medical forms and resulted in the burden increase.

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Annual Cost to Federal Government: $152,721

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: 07/21/2025

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