Self-Certification Medical Statement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form MRP Form 5-R Self Certification Medical Statement	Form	Modified	Available
0579-0196 2018 SS.pdf	Supporting Statement A	Uploaded 2018-02-22	Available
0579-0196 2018 APHIS 79.pdf	Supplementary Document	Uploaded 2018-01-23	Available
0579-0196 2018 APHIS 71.pdf	Supplementary Document	Uploaded 2018-01-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
2369	Self Certification Medical Statement	Form	Modified

ICR Details

OMB Control No: 0579-0196	ICR Reference No: 201801-0579-005
Status: Active	Previous ICR Reference No: 201412-0579-001
Agency/Subagency: USDA/APHIS	Agency Tracking No:
Title: Self-Certification Medical Statement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/20/2018
	Date Received in OIRA: 02/22/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2021	36 Months From Approved	04/30/2018
Responses	607	0	322
Time Burden (Hours)	102	0	54
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this information collection is to obtain self-certification of physical ability from job applicants to determine their fitness and ability to perform strenuous duties related to jobs with demanding physical or environmental conditions.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 55344	11/21/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 7450	02/21/2018
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Self Certification Medical Statement	MRP Form 5-R	Self-Certification Medical Statement

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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	607	322	0	1	284	0
Annual Time Burden (Hours)	102	54	0	1	47	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The number of responses and burden hours for this information collection increased substantially due to an increased number of estimated respondents. One additional program activity was added to account for requests for waiver. It added 1 response and 1 hour of burden to the ICR.

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Annual Cost to Federal Government: $4,081

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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

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Common Form ICR:  No

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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: 02/22/2018

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