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OMB Control No:	ICR Reference No: 202507-1117-003
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOJ/DEA	Agency Tracking No:
Title: DEA Voluntary Wellness Program Healthcare Provider Clearance
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 11/24/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	100	0
Time Burden (Hours)	75	0
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Change Due to Agency Discretion
Annual Number of Responses	100	100
Annual Time Burden (Hours)	75	75
Annual Cost Burden (Dollars)	0	0

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: Initial deployment of form/collection. Form necessary for receiving medical clearance to participate in the Voluntary Wellness Program. Medical appointments to complete the form are at voluntary cost to employees wishing to participate and thus are at 0 cost to the Federal Government.

Annual Cost to Federal Government:

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 Inks 571 672-4524 benjamin.b.inks@dea.gov