Fire and Aviation Medical Management Qualifications Program

Fire and Aviation Management Medical Qualifications Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0596-0164 can be found here:

Documents and Forms

Document Name Document Type
Form FS-5100-31 Fire and Aviation Medical Management Qualifications Program Form
FS-5100-31 Health Screening Questionnaire FS-5100-31_v032016.docx www.fs.fed.us/fire/safety/wct/wct_index.html Form
FS 5100-30 Work Capacity Test - Informed Consent FS-5100-30_v032016.docx www.fs.fed.us/fire/safety/wct/wct_index.html Form
FS-5100-32 Wildland Firefighter Medical Qualificiations Program Med FS-5100-32_v032016.docx Form
FS-5100-33 Self Certification Statement and Blood Pressure Check FS-5100-33_v032016.docx Form

Information Collection (IC) Details

IC Title:	Fire and Aviation Medical Management Qualifications Program	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 339

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FS-5100-31	Health Screening Questionnaire	FS-5100-31_v032016.docx	http://www.fs.fed.us/fire/safety/wct/wct_index.html	Yes	No	Fillable Printable
Form	FS 5100-30	Work Capacity Test - Informed Consent	FS-5100-30_v032016.docx	http://www.fs.fed.us/fire/safety/wct/wct_index.html	Yes	Yes	Fillable Printable
Form	FS-5100-32	Wildland Firefighter Medical Qualificiations Program Medical Exam	FS-5100-32_v032016.docx		Yes	No	Fillable Printable
Form	FS-5100-33	Self Certification Statement and Blood Pressure Check	FS-5100-33_v032016.docx		Yes	No	Fillable Printable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title: Privacy Act System of Records OPM/Govt-10 Employee Medical File Sys Records	FR Citation: 65 FR 24732

Number of Respondents: 34,950	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 40 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	89,520	19,620	44,640	25,260
Annual IC Time Burden (Hours)	10,289	5,396	2,796	2,097
Annual IC Cost Burden (Dollars)	0	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.