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60-Day Notice of Proposed Information Collection: Employee Self-Certification and Ability To Perform in Emergencies (ESCAPE) Posts, Pre-Deployment Physical Exam Acknowledgement Form

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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 January 7, 2020.


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-2019-0036” in the Search field. Then click the “Comment Now” button and complete the comment form.
  • Email:
  • Regular Mail: Send written comments to: Medical Director, Office of Medical Clearances, Bureau of Medical Services, 2401 E Street NW, SA-1, Room L-101, Washington, DC 20522-0101.
  • Fax: 202-647-0292 Attention: Medical Clearance Director.

You must include the DS form number (if applicable), information Start Printed Page 60466collection 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, should be sent to Karl Field, Director of Medical Clearances at 202-663-1591 or

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  • Title of Information Collection: Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) Posts, Pre-Deployment Physical Exam Acknowledgement Form.
  • OMB Control Number: 1405-0224.
  • Type of Request: Revision of a Currently Approved Collection.
  • Originating Office: Bureau of Medical Services; MED/CP/CL.
  • Form Number: DS-6570.
  • Respondents: Contractors deploying to ESCAPE Diplomatic Missions requesting access to the Department of State Medical Program (currently Iraq, Afghanistan, Yemen, Syria, Libya, Somalia and Peshawar).
  • Estimated Number of Respondents: 1,900.
  • Estimated Number of Responses: 1,900.
  • Average Time per Response: 40 minutes.
  • Total Estimated Burden Time: 1,266 hours.
  • Frequency: Annually for those deployed to an ESCAPE post.
  • 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.
  • 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 DS-6570 is completed by an individual and their medical provider to declare that the individual has health concerns that may represent a safety hazard for the individual or others at an ESCAPE Diplomatic Mission. ESCAPE is an acronym used to describe Diplomatic Missions overseas that are in extremely high threat, potentially combat, areas. Current ESCAPE Missions are Iraq, Afghanistan, Somalia, Libya, Yemen, Syria and Peshawar, Pakistan. This program is authorized under the Foreign Service Act of 1980, as implemented by the Department in 13 FAM 301.4-5.


The respondent will obtain the DS-6570 from his or her human resources representative, or will download the form from a Department website. The respondent will complete and submit the form offline.

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Karl Field,

Director of Medical Clearances.

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[FR Doc. 2019-24390 Filed 11-7-19; 8:45 am]