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 Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)	Form and Instruction	Modified	Available
Legal Authorities_ds6570.docx	Supplementary Document	Uploaded 2026-08-12	Available
Legal Authorities 1405-0224 (DS-6570).docx	Supplementary Document	Uploaded 2022-09-27	Available
DS6570 Supporting-Statement_2026.docx	Supporting Statement A	Uploaded 2026-08-12	Available

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

ICR Details

OMB Control No: 1405-0224	ICR Reference No: 202608-1405-002
Status: Received in OIRA	Previous ICR Reference No: 202209-1405-002
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	Date Submitted to OIRA: 08/12/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2026
Responses	1,900	532
Time Burden (Hours)	1,266	532
Cost Burden (Dollars)	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:
	91 FR 12946	02/17/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 13099	08/11/2026
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	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)

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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	1,900	532	0	1,368	0	0
Annual Time Burden (Hours)	1,266	532	0	734	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: The Office of Medical Clearances receives approximately 1,900 DS-6570 responses annually, taking approximately 30 minutes for respondents to complete the form. The annual hour time burden for respondents to complete the form is 1,266 hours (1,900 responses x 40 minutes / 60). The Department estimates that 1,900 non-federal physicians will be consulted by respondents. The physician will take approximately 30 minutes to complete the form. Their burden will be 950 hours (1,900 x 30 minutes/60).

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Annual Cost to Federal Government: $28,652

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: 08/12/2026

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