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OMB Control No: 1105-0099	ICR Reference No: 202406-1105-004
Status: Received in OIRA	Previous ICR Reference No: 201911-1105-001
Agency/Subagency: DOJ/LA	Agency Tracking No: 1105-0099
Title: USMS Medical Forms
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 07/21/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	1,139	0
Time Burden (Hours)	2,783	0
Cost Burden (Dollars)	157,014	0

Authorizing Statute(s): EO: EO 9397 Name/Subject of EO: Numbering system for federal accounts relating to individual persons
   US Code: 28 USC 566 Name of Law: Powers and duties
   US Code: 5 USC 3301 Name of Law: Civil service; generally
   US Code: 5 USC 3312 Name of Law: Preference eligibles; physical qualifications; waiver
   US Code: 5 USC 552a Name of Law: Records maintained on individuals
   US Code: 28 USC 561 Name of Law: United States Marshals Service

Citations for New Statutory Requirements: None

ICR Summary of Burden

	Total Request	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,139	27	1,112
Annual Time Burden (Hours)	2,783	68	2,715
Annual Cost Burden (Dollars)	157,014	4,293	152,721

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The SSO-012 form is a new form that was added to the USMS medical forms and resulted in the burden increase.

Annual Cost to Federal Government: $152,721

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Benjamin Cho 240 401-0008 benjamin.cho@usdoj.gov