Information Collection

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

IC 43932 under ICR 201601-1625-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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
1625-0040_Instr_r1_2017.docx	Instruction
CG-719B Application for Merchant Mariner Credential CG719B.pdf	Form and Instruction
CG-719C Disclosure Statement for Narcotics, DWI/DUI, and/or Othe CG719C.pdf	Form and Instruction
CG-719K Application for Medical Certificate CG719K.pdf	Form and Instruction
CG-719K/E Application for Medical Certificate, Short Form CG719KE.pdf	Form and Instruction
CG-719P DOT/USCG Periodic Drug Testing Form CG719P.pdf	Form
CG-719S Small Vessel Sea Service Form CG719S.pdf	Form

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.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			1625-0040_Instr_r1_2017.docx	Yes	Yes	Printable Only
Form and Instruction	CG-719B	Application for Merchant Mariner Credential	CG719B.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CG-719C	Disclosure Statement for Narcotics, DWI/DUI, and/or Other Convictions	CG719C.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CG-719K	Application for Medical Certificate	CG719K.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CG-719K/E	Application for Medical Certificate, Short Form	CG719KE.pdf	Yes	Yes	Fillable Printable
Form	CG-719P	DOT/USCG Periodic Drug Testing Form	CG719P.pdf	Yes	Yes	Fillable Printable
Form	CG-719S	Small Vessel Sea Service Form	CG719S.pdf	Yes	Yes	Fillable Printable

Line of Business: Transportation

Subfunction: Water Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 246,475

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	68,500	12,000	56,500
Annual IC Time Burden (Hours)	47,444	0	47,444
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.