Medical Clearance Update

OMB Control No: 1405-0131	ICR Reference No: 200107-1405-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical Clearance Update
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 08/31/2001
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/28/2001
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/31/2001
Terms of Clearance: OMB does not find the agency's emergency justification compelling since the PRA specifically requires the agency to undergo a review process prior to implementation of an information collection. The agency's wish to implement immediately does not automatically translate into a need. However, given that the agency has already implemented the form, in violation of the PRA, through a pilot program, OMB grants the request for emergency processing. All pilot programs in which 10 or more persons participate are covered by the PRA. Prior to future submission, the agency must reexamine its compliance with the Privacy Act and ensure the all respondents are adequately informed of the routine uses of this collection. The routine uses must be specifically detailed on or with the form. Cross-references to materials not immediately available to the respondent are not a suitable substitute. In addition, the agency may not require the respondent to provide the Social Security Number in the absence of specific statutory authorization to require it. The purpose for collecting the Social Security Number must be disclosed on the form, whether providing it is mandatory or voluntary.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2002	02/28/2002
Responses	12,000	0	0
Time Burden (Hours)	3,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Forms are used by the Health Promotion Program of the Office of Medical Services. They become part of the individual's medical record and are used by the Examination and Clearance Sections medical personnel to enable medevac assignment decisions to be made. Upon completion by the individual, medically confidential information is included that should not be transmitted via the Intranet or Internet. By law, they can be reviewed only be the individual and his or her designated caregiver unless expressed written permission is granted by the examinee.

Emergency Justfication:

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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:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name Medical Clearance Update DS-3057

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ICR Summary 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	12,000	0	0	12,000	0	0
Annual Time Burden (Hours)	3,000	0	0	3,000	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:

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: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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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: 07/31/2001

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