Medical Clearance Update

Forms and Documents

Document Name	Status
Form DS-3057 Medical Clearance Update Form and Instruction	Modified
Justification for Change-DS3057-3.17.2025.docx Justification for No Material/Nonsubstantive Change	2025-03-18
Supporting Statement - DS-3057 12-12-23.docx Supporting Statement A	2023-12-18
Legal Authorities 1405-0131(9-7-2023).docx Supplementary Document	2023-12-08
1405-0131_30 day Published.pdf Supplementary Document	2023-01-26
PublishedFR_11-07-2022.pdf Supplementary Document	2023-01-26
Legal Authorities 1405-0131(Updated).docx Supplementary Document	2023-01-26

IC Document Collections

IC ID	Document Title	Status
264603	Medical Clearance Update Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0131	ICR Reference No: 202503-1405-004
Status: Received in OIRA	Previous ICR Reference No: 202312-1405-004
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical Clearance Update
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/18/2025

	Requested	Previously Approved
Expiration Date	01/31/2027	01/31/2027
Responses	8,782	8,782
Time Burden (Hours)	4,391	4,391
Cost Burden (Dollars)	0	0

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Abstract: The information requested on the DS-3057 is required for professional medical staff of the Bureau of Medical Services to make decisions on the type of medical clearance an individual and family members are assigned. This medical clearance, in turn, is used by the Foreign Service to determine posts abroad where the Foreign Service member and family may serve.

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Authorizing Statute(s): US Code: 22 USC 2651a Name of Law: Authorities of the Secretary
   US Code: 22 USC 3901 Name of Law: Foreign Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 12199	10/02/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 12279	12/08/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medical Clearance Update	DS-3057	Medical Clearance Update

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	8,782	8,782	0	0	0	0
Annual Time Burden (Hours)	4,391	4,391	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: The Office of Medical Clearances receives approximately 8,782 DS-3057 responses annually, with an estimation of 30 minutes for respondents to complete the form. The annual hour time burden for respondents to complete the form is 4,391 annual hours (8,782 responses x 30 minutes / 60).

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Annual Cost to Federal Government: $108,651

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

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/18/2025

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