Fire and Aviation Management Medical Qualifications Program

ICR 201701-0596-002

OMB: 0596-0164

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Justification for No Material/Nonsubstantive Change
2017-02-09
Supplementary Document
2016-03-30
Supporting Statement A
2016-03-30
IC Document Collections
ICR Details
0596-0164 201701-0596-002
Historical Active 201603-0596-004
USDA/FS
Fire and Aviation Management Medical Qualifications Program
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 02/10/2017
Retrieve Notice of Action (NOA) 02/09/2017
  Inventory as of this Action Requested Previously Approved
06/30/2019 06/30/2019 06/30/2019
89,520 0 89,520
10,289 0 10,289
0 0 0

Medical history, which is provided by completing the Health Screening Questionaire, Medical Qualifications Program Medical Exam and Self-Certification Statement 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.

US Code: 16 USC 594 Name of Law: The Protection Act of 1922
  
None

Not associated with rulemaking

  81 FR 459 01/06/2016
81 FR 17135 03/28/2016
Yes

  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 89,520 89,520 0 0 0 0
Annual Time Burden (Hours) 10,289 10,289 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The program change increase is for two new forms, FS-5100-32 and FS-5100-33. The adjustment increase covers an increase in respondents and an increase in the number of medical qualification exams done annually for safety reasons.

$152,959
No
No
No
No
No
Uncollected
Kerri Mills 202 205-9967 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/09/2017


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