Self - Certification Medical Statement

Forms and Documents

Document Name	Status
Form MRP-5 Self Certification Medical Statement Form	Modified
SS 0196.docx Supporting Statement A	2011-11-01
APHIS79.pdf Supplementary Document	2011-10-06
2011 APHIS 71 - 0196.xlsm Supplementary Document	2011-10-06

IC Document Collections

IC ID	Document Title	Status
2369	Self Certification Medical Statement Form	Modified

ICR Details

OMB Control No: 0579-0196	ICR Reference No: 201110-0579-007
Status: Historical Active	Previous ICR Reference No: 200710-0579-002
Agency/Subagency: USDA/APHIS	Agency Tracking No:
Title: Self - Certification Medical Statement
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: 12/20/2011
	Date Received in OIRA: 11/02/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved	12/31/2011
Responses	524	0	600
Time Burden (Hours)	88	0	100
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this collection is to obtain medical information regarding the employment decisions for a job applicant.

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Authorizing Statute(s): None

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:
	5 FR 339	07/01/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 207	10/26/2011
Did the Agency receive public comments on this ICR? No

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

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

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ICR Summary 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	524	600	0	0	-76	0
Annual Time Burden (Hours)	88	100	0	0	-12	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: In the previous collection there were 600 respondents, 600 responses, and 100 burden hours, due to an adjustment decrease in respondents to 524 this reduced the number of respondents and responses to 524 a difference of 76, and the number of burden hours to 88 reducing the total burden hours by 12. The adjusted decrease is due to a decrease in the number of respondents who complete the Self-Certification Medical Statement annually.

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Annual Cost to Federal Government: $3,281

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 11/02/2011

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