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60-Day Notice of Proposed Information Collection: Overseas Pre-Assignment Medical History and Examination, Non-Foreign Service Personnel and Their Family Members

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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 May 26, 2017.


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-2016-0074” in the Search field. Then click the “Comment Now” button and complete the comment form.
  • Email:
  • Regular Mail: Send written comments to: Department of State, Office of Medical Clearances, SA-15 Room 400, 1800 North Kent St., Rosslyn, VA 22209.
  • Fax: 703-875-4850.

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: Overseas Pre-Assignment Medical History and Examination, Non-Foreign Service Personnel and Their Family Members.
  • OMB Control Number: 1405-0194.
  • Type of Request: Revision of a Currently Approved Collection.
  • Originating Office: Bureau of Medical Services—Medical Clearances.
  • Form Number: DS-6561.
  • Respondents: Non-foreign service employees or family members.
  • Estimated Number of Respondents: 9,890.
  • Estimated Number of Responses: 9,890.
  • Average Time per Response: 1 hour.
  • Total Estimated Burden Time: 9,890 hours.
  • Frequency: As needed.
  • Obligation to Respond: Required to Obtain or Retain 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.Start Printed Page 15268
  • 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: Form DS-6561 is designed to succinctly collect appropriate and current medical information about an individual in order for a medical provider to make a determination as to whether a federal employee or contractor or eligible family member will have sufficient medical and educational resources at a diplomatic mission abroad to maintain the health and safety of the individual or family member. It is designed for all non-Foreign Affairs Agency employees, or their eligible family members.

Methodology: The information collected will be collected through the use of an electronic forms engine or by hand written submission using a pre-printed form.

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Behzad Shahbazian,

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

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[FR Doc. 2017-05951 Filed 3-24-17; 8:45 am]