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30-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 and submission to OMB of proposed collection of information.


The Department of State has submitted the information collection described below to the Office of Management and Budget (OMB) for approval. 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 30 days for public comment.


Submit comments directly to the Office of Management and Budget (OMB) up to February 18, 2020.


Direct comments to the Department of State Desk Officer in the Office of Information and Regulatory Affairs at the Office of Management and Budget (OMB). You may submit comments by the following methods:

  • Email: You must include the DS form number, information collection title, and the OMB control number in the subject line of your message.
  • Fax: 202-395-5806. Attention: Desk Officer for Department of State.
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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: Karl Field, Medical Director, Office of Medical Clearances, Bureau of Medical Services, 2401 E Street NW, SA-1, Room L-101, Washington, DC 20522-0101, and who may be reached at 202-663-1591 or at

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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: 30 minutes.
  • Total Estimated Burden Time: 950 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. 2020-00763 Filed 1-16-20; 8:45 am]