OF 178 Certificate of Medical Examination

Forms and Documents

Document Name	Status
Form OF 178 Certificate of Medical Examination Form and Instruction	Modified
SSA_3206-0250 of 1781.DOC Supporting Statement A	2012-04-25
30 day notice of 178.pdf Supplementary Document	2012-01-26
3206-0250 60 day notice.pdf Supplementary Document	2012-01-05

IC Document Collections

IC ID	Document Title	Status
187036	Certificate of Medical Examination Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0250	ICR Reference No: 201202-3206-002
Status: Historical Active	Previous ICR Reference No: 201112-3206-003
Agency/Subagency: OPM	Agency Tracking No:
Title: OF 178 Certificate of Medical Examination
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/26/2012
	Date Received in OIRA: 02/02/2012
Terms of Clearance: This collection is cleared based on the revised materials provided by the Agency.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2015	36 Months From Approved	04/30/2012
Responses	45,000	0	45,000
Time Burden (Hours)	135,000	0	135,000
Cost Burden (Dollars)	0	0	0

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Abstract: The changes in this submission include a Genetic Information Nondiscrimination Act (GINA) disclosure statement and changes to the Program Office name. The medical information to be collected using Optional Form (OF) 178, Certificate of Medical Exmination is needed to determine whether an incumbent or applicant for a Federal position which requires physical fitness/agility testing and/or medical examinations as a condition of employment meets the physical requirements of the position, to ensure fair and consistent treatment of employees and job applicants and to adjudicate passover of a preference eligible and claims of discrimination under the Americans with Disabilities Act (ADA).

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Authorizing Statute(s): US Code: 5 USC 3504 Name of Law: Preference eligibles; retention; physical qualifications; waiver
   US Code: 5 USC 3312 Name of Law: Veteran Preference Rights
   US Code: 5 USC 3318 Name of Law: Competitive Service; Selection from certificates
   US Code: 5 USC 339 Name of Law: Medical Qualification Determinations
   US Code: 5 USC 351.702(d) Name of Law: Qualifications for Assignment
  

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:
	76 FR 81999	12/29/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 4061	01/26/2012
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
Certificate of Medical Examination	OF 178	Certificate of Medical Examination

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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	45,000	45,000	0	0	0	0
Annual Time Burden (Hours)	135,000	135,000	0	0	0	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:

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Annual Cost to Federal Government: $127,182

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: 02/02/2012

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