OMB control number

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

OMB 1405-0224 · STATE/AFA.

OMB 1405-0224

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.

The latest form for Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) expires 2026-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form DS-6570 Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Form and Instruction
Legal Authorities 1405-0224 (DS-6570).docx Supplementary Document
Supporting Statement 1405-0224 (DS-6570) 30day.docx Supporting Statement A
Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Form and Instruction

All Historical Document Collections

202209-1405-002 Approved without change	Revision of a currently approved collection	2022-09-27
202001-1405-002 Approved with change	Revision of a currently approved collection	2020-01-31
201611-1405-004 Approved without change	Revision of a currently approved collection	2016-11-28
201605-1405-002 Approved without change	New collection (Request for a new OMB Control Number)	2016-05-10