Information Collection

Self Certification Medical Statement

IC 2369 under ICR 200710-0579-002 · OMB 0579-0196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0579-0196 can be found here:

Documents and Forms

Document Name Document Type
Form MRP-5 Self Certification Medical Statement Form
MRP-5 Self - Certification Medical Statement MRP-5 Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Self Certification Medical Statement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	MRP-5	Self - Certification Medical Statement	MRP-5 Form.pdf		No		Paper Only

Line of Business: Natural Resources

Subfunction: Agricultural Innovation and Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	600	300	300
Annual IC Time Burden (Hours)	100	50	50
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.