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OMB Control No: 1405-0224	ICR Reference No: 202608-1405-002
Status: Received in OIRA	Previous ICR Reference No: 202209-1405-002
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 08/12/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2026
Responses	1,900	532
Time Burden (Hours)	1,266	532
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	1,900	532	1,368
Annual Time Burden (Hours)	1,266	532	734
Annual Cost Burden (Dollars)	0	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: The Office of Medical Clearances receives approximately 1,900 DS-6570 responses annually, taking approximately 30 minutes for respondents to complete the form. The annual hour time burden for respondents to complete the form is 1,266 hours (1,900 responses x 40 minutes / 60). The Department estimates that 1,900 non-federal physicians will be consulted by respondents. The physician will take approximately 30 minutes to complete the form. Their burden will be 950 hours (1,900 x 30 minutes/60).

Annual Cost to Federal Government: $28,652

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: Claire Whitacre 771 205-9036

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