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⚠️ Notice: This information collection may be referencing outdated material.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 Rev corrected version JS_2.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-5100-41 USFS Wildland Firefighter Medical Qualifications Program FS-5100-41 corrected version JS.docx Form
FS-5100-42 Self Certification Statement and Blood Pressure Check FS-5100-42_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 Rev corrected version JS_2.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-5100-41	USFS Wildland Firefighter Medical Qualifications Program Physical Exam	FS-5100-41 corrected version JS.docx		Yes	No	Fillable Printable
Form	FS-5100-42	Self Certification Statement and Blood Pressure Check	FS-5100-42_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	Previously Approved
Annual Number of Responses for this IC	89,520	89,520
Annual IC Time Burden (Hours)	10,289	10,289
Annual IC Cost Burden (Dollars)	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.