0579-0196 2018 Aphis 79

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OMB Control No.
0579-0196

Self-Certification Medical Statement

Total Annual
Responses

Form Number or Other Identification

(A)

(B)

Self-Certification Medical Statement
(MRP Form 5-R)
Request for Waiver of Standards and
Requirements

Avg. Time Per
Response

(C)

Total Hours
Per Year

Persons Involved in the
Information Collection*

Program Costs

Overhead
Costs

Total Costs

(B x C)

Grade (GS)

Avg. Hourly
Rate (Step 4)

(D x (E.2))

(F x 0.139)

(F + G)

(D)

(E.1)

(E.2)

(F)

(G)

(H)

606

0.167

101

11

$

35.06

$

3,548.14

$

493.19

$

4,041.33

1

1.000

1

11

$

35.06

$

35.06

$

4.87

$

39.93

$

4,081.27

TOTALS

APHIS Form 79

Worksheet for Calculating Costs to the Federal Government for Information Collection

Remarks

(I)

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