Information Collection

Certificate of Medical Examination

IC 187036 under ICR 201112-3206-003 · OMB 3206-0250.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0250 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OF 178 Certificate of Medical Examination	Form and Instruction
OF 178 Certificate of Medical Examination OF178.pdf	Form and Instruction

IC Title:

Certificate of Medical Examination

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 339

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OF 178	Certificate of Medical Examination	OF178.pdf		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title: OPM/GOVT-10, Employee Medical File System Records

FR Citation: 71 FR 35360

Number of Respondents: 45,000

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	45,000	45,000
Annual IC Time Burden (Hours)	135,000	135,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.