Supporting-Statement MED

SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION

Pre-Employment Medical and Driver Medical Evaluation Forms
OMB Number 1405-XXXX
DS-6571, DS-6572, DS-6573, DS-6574, DS-6575, DS-6576, DS-6577

A. JUSTIFICATION

1. This collection is necessary for the U.S. Department of State’s (DOS) Bureau of Medical Services (MED) to evaluate medical eligibility for employment and operating a government owned vehicle (GOV) overseas, and for gathering supplemental pertinent medical information regarding identified conditions that could pose a safety risk to employees and others. This collection consists of seven forms, the pre-employment evaluation for locally employed staff (LES) (DS-6571), a tuberculosis (TB) risk assessment (DS-6573), a driver medical evaluation (DME) for US Direct Hires (USDH) (DS-6576), a DME for LES (DS-6572), and supplemental health questionnaires. The supplemental health questionnaires are utilized for vision related (DS-6577), seizure related (DS-6574), and diabetes related diagnoses (DS-6575). These questionnaires and concurrent medical evaluations are required to make informed assessments on ability to complete required employment-related tasks; implementation of this collection is pursuant to 5 CFR § 930.108, § 339.301, and the Foreign Service Act of 1980, as amended, 22 U.S.C. §§ 4084, 3901, and 3984. This collection is designed to capture the minimum required information to assess medical eligibility and to comply with these statutes.

2. The information collected in the forms is utilized to determine if a candidate/employee is medically eligible for employment and/or to obtain the driver certificate required to operate a GOV overseas. If a medical condition is identified during the evaluation, local Health Unit (HU) health care providers will advise the individual to follow-up with the appropriate specialty care.

3. This collection of forms is not currently available for electronic completion. However, MED is actively pursuing the capability to electronically submit these forms and is moving away from the current practice of maintaining paper records. The collection will be downloaded from the MED SharePoint site by MED staff, given to the individual via email, printed, filled out by the local provider, and is locally stored at the HU.

4. The information collected is generally not duplicated across collections, apart from demographic information, including basic identification and contact information. The medical information that is collected on the forms can routinely change from one evaluation to the next, as can post, address, type of employment, and other information.

5. This collection could impact small businesses or other small entities. If the prospective or current employee undergoing medical evaluation requires additional medical services, the HU provider overseeing the evaluation can refer the candidate/employee out to a medical specialist for more information. Alternatively, at some locations, the evaluations and/or supplemental evaluations can be performed by local providers.

6. Per Title 5 of the United States Code, the Department is required to “ensure that employees who operate Government-owned or leased vehicles are medically able to do so without undue risk to themselves or others”; violation of this regulation could result in unsafe driving conditions for employees and civilians overseas. DS-6570 and supplemental forms is intended to comply with 5 CFR § 930.108.

7. There are no special collection circumstances.

8. On May 23, 2024, the Department published a notice in the Federal Register soliciting public comments for a period of 60 days. 89 FR 45726. There were no public comments.

9. The Department does not make any payments or give gifts to the respondent.

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

11. The collection includes questions about current and past medical conditions that can be considered sensitive in nature, specifically regarding, but not limited to, mental health, medication usage, and existence of immunocompromising diagnoses. All information collected is protected under the Privacy Act and the Genetic Information Nondiscrimination Act (GINA), which protects individuals against discrimination based on their genetic information in health coverage and employment.

12. The respondents in this collection are all medical providers, who will be evaluating either U.S. Direct Hire (USDH) or Locally Employed Staff (LES). The estimated completion time for the DS- forms is as follows:

6571 (Med Eval for LES non-drivers) – 60 min

6572 (Driver Medical Eval for LES) – 60 min

6573 (TB Risk Assessment) – 60 min

6574 (Seizure/Epilepsy) – 15 min

6575 (Diabetes) – 60 min

6576 (USDH Driver) – 60 min

6577 (Vision Assessment) – 30 min

Not all respondents will fill out all seven forms. It is anticipated that the breakdown will be as follow (italics means as needed):

Category	Number of evals per year	Forms	Time*	Burden Hours
USDH Driver	5800	6576 (6574, 6575, 6577)	165	15950
LES driver	2400	6572 & 6573 (6574, 6575, 6577)	225	9000
LES (non driver)	4800	6571 & 6573	120	9600

*assumes all of the listed forms were used, including italics.

Total respondents: 13,000

Total time: 34,550 hours

The median wage for a medical professional is $119.54. The weighted hourly wage (x 1.2) is $143.45. The time cost burden is $143.45 x 34,500 = $4,956,128.¹ Again, this is a high estimate to cover this entire collection. Each medical professional will fill out a subset of the forms.

13. There are no direct monetary costs to respondents.

14. Costs incurred by the Federal government to complete this collection are related to DoS employee labor to review the seven potential forms from 13,000 respondents. The total average cost per office support staff employed by DoS, factoring wage, benefits, and overhead, is $84.13 per hour. Each form review will require 15 minutes of office support staff time. The high-end estimate of cost to the Federal government is 13,000 x $84.13 x ¼ = $273,423. This is a high estimate because not all forms will be used by a particular respondent.

15. This is a new collection and has not been previously submitted.

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

17. The Department will display the OMB expiration date.

18. The department is not seeking exceptions to the certification statement.

B. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS

1. This collection does not employ statistical methods.

1 https://www.bls.gov/oes/current/oes291229.htm