Health Screening Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FS-5100-31 Health Screening Questionnaire-Forest Service	Form	Modified	Available
0596-0164 Form 5100-30 Revision_Justification for Change Statement_July2015.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2015-07-01	Available
Spread Sheet for 0596-0164.pdf	Supplementary Document	Uploaded 2013-01-17	Available
0596-0164 2013 renwal Supporting Statement v01-14-13.docx	Supporting Statement A	Uploaded 2013-01-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43556	Health Screening Questionnaire-Forest Service	Form	Modified

ICR Details

OMB Control No: 0596-0164	ICR Reference No: 201506-0596-007
Status: Historical Active	Previous ICR Reference No: 201212-0596-001
Agency/Subagency: USDA/FS	Agency Tracking No:
Title: Health Screening Questionnaire
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/08/2015
	Date Received in OIRA: 07/01/2015
Terms of Clearance: In accordance with 5 CFR 1320, this information collection is approved for 3 years.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	03/31/2016	03/31/2016
Responses	25,260	0	25,260
Time Burden (Hours)	2,097	0	2,097
Cost Burden (Dollars)	0	0	0

---

Abstract: Medical history, which is provided by completing the Health Screening Questionaire, supplies information needed to determine certification of suitability, any special medical or medication needs, and a file record to protect both the Federal Government and individuals.

---

Authorizing Statute(s): US Code: 16 USC 594 Name of Law: The Protection Act of 1922
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 39986	07/06/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 3878	01/17/2013
Did the Agency receive public comments on this ICR? Yes

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Health Screening Questionnaire-Forest Service	FS 5100-30, FS-5100-31	Health Screening Questionnaire ,   Work Capacity Test - Informed Consent

---

ICR Summary of Burden

table that charts list 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	25,260	25,260	0	0	0	0
Annual Time Burden (Hours)	2,097	2,097	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: Between FS and DOI the respondents increased by 7,233 thus increasing responses by 14,466 and burden by 1,201 hours for this submission.

---

Annual Cost to Federal Government: $135,300

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

---

Common Form ICR:  No

---

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: 07/01/2015

---