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60-Day Notice of Proposed Information Collection: Self Certification and Ability To Perform In Emergencies (ESCAPE) Program

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Notice of request for public comment.


The Department of State is seeking Office of Management and Budget (OMB) approval for the information collection described below. In accordance with the Paperwork Reduction Act of 1995, we are requesting comments on this collection from all interested individuals and organizations. The purpose of this notice is to allow 60 days for public comment preceding submission of the collection to OMB.


The Department will accept comments from the public up to November 8, 2016.


You may submit comments by any of the following methods:

  • Web: Persons with access to the Internet may comment on this notice by going to You can search for the document by entering “Docket Number: DOS-2016-0058” in Start Printed Page 62548the Search field. Then click the “Comment Now” button and complete the comment form.
  • Email:
  • Regular Mail: Send written comments to: Department of State, Bureau of Medical Services—Medical Clearances, SA-15 Room 400, 1800 North Kent St., Rosslyn, VA. 22209.
  • Fax: 703-875-5412.

You must include the DS form number (if applicable), information collection title, and the OMB control number in any correspondence.

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Direct requests for additional information regarding the collection listed in this notice, including requests for copies of the proposed collection instrument and supporting documents, to Joan F. Grew, who may be reached on 703-875-5412 or at

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  • Title of Information Collection: Self Certification and Ability To Perform in Emergencies (ESCAPE) Program.
  • OMB Control Number: 1405-0224.
  • Type of Request: Revision of a Currently Approved Collection.
  • Originating Office: Bureau of Medical Services (MED).
  • Form Number: DS-6570.
  • Respondents: Non-federal individuals being considered for contracted assignments at ESCAPE-designated posts.
  • Estimated Number of Respondents: 200.
  • Estimated Number of Responses: 200.
  • Average Time per Response: 30 minutes.
  • Total Estimated Burden Time: 100 annual hours.
  • Frequency: One time per deployment to ESCAPE post.
  • Obligation to Respond: Required to obtain a benefit.

We are soliciting public comments to permit the Department to:

  • Evaluate whether the proposed information collection is necessary for the proper functions of the Department.
  • Evaluate the accuracy of our estimate of the time and cost burden for this proposed collection, including the validity of the methodology and assumptions used.
  • Enhance the quality, utility, and clarity of the information to be collected.
  • Minimize the reporting burden on those who are to respond, including the use of automated collection techniques or other forms of information technology.

Please note that comments submitted in response to this Notice are public record. Before including any detailed personal information, you should be aware that your comments as submitted, including your personal information, will be available for public review.

Abstract of Proposed Collection

The goal of the “Self Certification And Ability To Perform In Emergencies” (ESCAPE) program is to ensure that non-federal individuals who are being considered for a contracted position at a designated post are capable of the unique, potentially challenging and life threatening conditions at ESCAPE posts. These individuals are required to review with a medical provider the pre-deployment acknowledgement form (DS-6570) and then affirm that they understand the physical rigors and security conditions at these posts and can perform any specified emergency functions. Medical information is collected from medical providers and respondents during this review. The Department of State is requesting approval of this Information Collection so non-federal individuals who will be selected for assignments can provide completed pre-deployment medical information. This Collection is allowed under the Foreign Service Act of 1980 (22 U.S.C. 3901) and the Basic Authorities Act of 1956 (22 U.S.C. 2651).


The information collected will be collected using a form (DS-6570) during a medical review between a non-federal individual and his/her medical provider. The individual will submit the completed form, signed by both the individual and provider, to the Bureau of Medical Services at the U.S. Department of States.

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Dated: September 1, 2016.

Behzad Shahbazian,

Director of Clinical Services, Bureau of Medical Services, Department of State.

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[FR Doc. 2016-21756 Filed 9-8-16; 8:45 am]