Information Collection

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

IC 221440 under ICR 202001-1405-002 · OMB 1405-0224.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0224 can be found here:

Documents and Forms

Document Name Document Type
Form DS-6570 Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Form and Instruction
DS-6570 Employee Self-Certification and Ability to Perform in Em DS-6570 - DRAFT - 10-28-2019v3.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-6570	Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Posts PRE-DEPLOYMENT PHYSICAL EXAM ACKNOWLEDGEMENT FORM	DS-6570 - DRAFT - 10-28-2019v3.pdf		No		Fillable Fileable

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 532	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	532	332	200
Annual IC Time Burden (Hours)	532	432	100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.