PHYSICIAN STATEMENT OF CLEARANCE FOR AN EXERCISE PROGRAM

ICR 199101-1545-012

OMB: 1545-1044

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
131419
Migrated
ICR Details
1545-1044 199101-1545-012
Historical Active 198906-1545-034
TREAS/IRS
PHYSICIAN STATEMENT OF CLEARANCE FOR AN EXERCISE PROGRAM
Extension without change of a currently approved collection   No
Regular
Approved without change 04/01/1991
Retrieve Notice of Action (NOA) 01/29/1991
  Inventory as of this Action Requested Previously Approved
03/31/1994 03/31/1994 03/31/1991
20,000 0 20,000
2,000 0 2,000
0 0 0

THIS CONSENT FORM IS NECESSARY SO THAT ALL IRS EMPLOYEES CAN BE CONSIDERED MEDICALLY SAFE AND CLEARED BY THEIR PERSONAL PHYSICIAN FOR THE HEALTH IMPROVEMENT PROGRAM. THE FORM WILL REMAIN IN EACH EMPLOYEE'S PRIVATE FITNESS FILE, IN LOCKED FILE CABINETS. ONLY PHYSICIANS CAN FILL IT OUT AND THEREBY BE AFFECTED BY THIS FORM.

None
None


No

1
IC Title Form No. Form Name
PHYSICIAN STATEMENT OF CLEARANCE FOR AN EXERCISE PROGRAM

  Total Approved 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 20,000 20,000 0 0 0 0
Annual Time Burden (Hours) 2,000 2,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/29/1991


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