Self Certification Medical Statement

ICR 200504-0579-003

OMB: 0579-0196

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
2369 Migrated
ICR Details
0579-0196 200504-0579-003
Historical Active 200204-0579-002
USDA/APHIS
Self Certification Medical Statement
Extension without change of a currently approved collection   No
Regular
Approved without change 08/04/2005
Retrieve Notice of Action (NOA) 04/13/2005
  Inventory as of this Action Requested Previously Approved
08/31/2008 08/31/2008 08/31/2005
300 0 300
50 0 50
0 0 0

The information collected from the prospective employees will assist Program officials, administrative personnel, and servicing Human Resources offices to determine an applicant's physical fitness and suitability for employment in positions with approved medical standards and physical requirements who have direct contact with meat, dairy, fresh or processed fruits and vegetables, and poultry intended for human consumption and cotton and tobacco products intended for consumer use. These postions involve arduous duties, promimity to moving machinery, slippery surfaces, and exposure to high noise levels.

None
None


No

1
IC Title Form No. Form Name
Self Certification Medical Statement MRP-5

  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 300 300 0 0 0 0
Annual Time Burden (Hours) 50 50 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.
04/13/2005


© 2024 OMB.report | Privacy Policy