Health Screening Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FS 5100-30 Work Capacity Test - Informed Consent	Form	Modified	Available
Form FS-5100-31 Health Screening Questionnaire	Form	Modified	Available
REV_Supporting_Statement_OMB-0596-0164_20090828.doc	Supporting Statement A	Uploaded 2009-08-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43556	Health Screening Questionnaire	Form	Modified	Work Capacity Test - Informed Consent
43556	Health Screening Questionnaire	Form	Modified	Health Screening Questionnaire

ICR Details

OMB Control No: 0596-0164	ICR Reference No: 200907-0596-002
Status: Historical Active	Previous ICR Reference No: 200606-0596-002
Agency/Subagency: USDA/FS	Agency Tracking No:
Title: Health Screening Questionnaire
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/26/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/28/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2013	36 Months From Approved	01/31/2010
Responses	10,794	0	10,552
Time Burden (Hours)	896	0	876
Cost Burden (Dollars)	0	0	0

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Abstract: Medical history, which is provided by completing the Health Screening Questionaire, supplies information needed to determine certification of suitability, any special medical or medication needs, and a file record to protect both the Federal Government and individuals.

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Authorizing Statute(s): US Code: 16 USC 594 Name of Law: The Protection Act of 1922
  

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:
	73 FR 230	11/28/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 163	08/25/2009
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Health Screening Questionnaire	FS-5100-31, FS 5100-30	Health Screening Questionnaire ,   Work Capacity Test - Informed Consent

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ICR Summary of Burden

table that charts list of burden

	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	10,794	10,552	0	0	242	0
Annual Time Burden (Hours)	896	876	0	0	20	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: There was an increase in applicants resulting in an increase of 20 burden hours.

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Annual Cost to Federal Government: $622,512

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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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: 08/28/2009

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