Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical

Application for Merchant Mariner Credential (MMC), Application for Merchant Mariner Medical Certificate, Application for Merchant Mariner Medical Certificate for Entry Level Ratings, Small Vessel Sea

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1625-0040 can be found here:

Documents and Forms

Document Name Document Type
Form CG-719S Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical Form and Instruction
1625-0040_Instruction_r0_23Jan2014.docx Instruction
CG-719S Small Vessel Sea Service Form CG719S.pdf www.uscg.mil/forms Form and Instruction
CG-719K Merchant Mariner Medical Evaluation Report CG-719K_9April2014.pdf www.uscg.mil/forms Form and Instruction
CG-719K/E Merchant Mariner Evaluation of Fitness For Entry Level R CG-719KE_3Jan2013.pdf www.uscg.mil/forms Form and Instruction
CG-719P DOT/USCG Periodic Drug Testing Form CG719P_3Jan2013.pdf www.uscg.mil/forms Form and Instruction
CG-719S Small Vessel Sea Service Form CG-719S_3Jan2013.pdf www.uscg.mil/forms Form and Instruction
CG-719B Application For Merchant Mariner Credential (MMC) Draft_CG-719B.pdf www.uscg.mil/forms Form and Instruction
CG-719C Disclosure Statement for Narcotics, DWI/DUI, and/or Othe CG-719C CG vendor version_14Feb14.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 46 CFR 10.105(b) 46 CFR 11 46 CFR 12 46 CFR 13 46 CFR 16

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CG-719K/E	Merchant Mariner Evaluation of Fitness For Entry Level Ratings	CG-719KE_3Jan2013.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719S	Small Vessel Sea Service Form	CG-719S_3Jan2013.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719P	DOT/USCG Periodic Drug Testing Form	CG719P_3Jan2013.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Instruction			1625-0040_Instruction_r0_23Jan2014.docx		Yes	Yes	Printable Only
Form and Instruction	CG-719S	Small Vessel Sea Service Form	CG719S.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719B	Application For Merchant Mariner Credential (MMC)	Draft_CG-719B.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719K	Merchant Mariner Medical Evaluation Report	CG-719K_9April2014.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719C	Disclosure Statement for Narcotics, DWI/DUI, and/or Other Convictions	CG-719C CG vendor version_14Feb14.pdf		Yes	Yes	Fillable Printable

Line of Business: Transportation

Subfunction: Water Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 259,606	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 10 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	68,500	12,000	56,500
Annual IC Time Burden (Hours)	47,444	3,186	44,258
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.