Information Collection

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

IC 43932 under ICR 201409-1625-011 · OMB 1625-0040.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CG-719K (01/14) Application for Merchant Mariner Medical Certificate Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical	Form and Instruction
Form CG-719K/E (01/14) Application for Merchant Mariner Medical Certificate for Entry Level Ratings Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical	Form and Instruction
Form CG-719P (01/14) DOT/USCG Periodic Drug Testing Form Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical	Form and Instruction
Form CG-719S (01/14) Small Vessel Sea Service Form Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical	Form and Instruction
Form CG-719C (01/14) Disclosure Statement for Narcotics, DWI/DUI, AND/OR Other Convictions Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical	Form and Instruction
Form CG-719B Application for Merchant Mariner Credential (MMC) 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-719K (01/14) Application for Merchant Mariner Medical Certificate CG-719K CG vendor version_13Mar14.pdf www.uscg.mil/forms	Form and Instruction
CG-719K/E (01/14) Application for Merchant Mariner Medical Certificate for CG-719KE CG vendor version_12Mar14.pdf www.uscg.mil/forms	Form and Instruction
CG-719P (01/14) DOT/USCG Periodic Drug Testing Form CG-719P CG vendor version_14Feb14.pdf www.uscg.mil/forms	Form and Instruction
CG-719S (01/14) Small Vessel Sea Service Form CG-719S CG vendor version_11Feb14.pdf www.uscg.mil/forms	Form and Instruction
CG-719C (01/14) Disclosure Statement for Narcotics, DWI/DUI, AND/OR Othe CG-719C CG vendor version_14Feb14.pdf www.uscg.mil/forms	Form and Instruction
CG-719B Application for Merchant Mariner Credential (MMC) CG-719B CG vendor version_12Mar14.pdf www.uscg.mil/forms	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Yes	Yes	Printable Only
Form and Instruction	CG-719K (01/14)	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719K/E (01/14)	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719P (01/14)	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719S (01/14)	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719C (01/14)	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719B	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	56,500	0	56,500
Annual IC Time Burden (Hours)	47,444	3,186	44,258
Annual IC Cost Burden (Dollars)	0	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.

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