Health Screen Questionarie (HSQ)

ICR 200107-0596-001

OMB: 0596-0164

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
3271 Migrated
ICR Details
0596-0164 200107-0596-001
Historical Active
USDA/FS
Health Screen Questionarie (HSQ)
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 08/31/2001
Retrieve Notice of Action (NOA) 07/11/2001
  Inventory as of this Action Requested Previously Approved
10/31/2004 10/31/2004
1,500 0 0
1,250 0 0
0 0 0

The health screening forms permit access to employment in wildland firefighting in the Forest Service. The applicant who is selected for employment must submit medical history forms verifying their physcial suitability for the program. If not used, Government liability risk would be high and the special needs of an individual would not be know.

None
None


No

1
IC Title Form No. Form Name
Health Screen Questionarie (HSQ) FS-5100-30, FS-5100-31

  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 1,500 0 0 1,500 0 0
Annual Time Burden (Hours) 1,250 0 0 1,250 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
07/11/2001


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