Information Collection

Self Certification Medical Statement

IC 2369 under ICR 201801-0579-005 · OMB 0579-0196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0579-0196 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form MRP Form 5-R Self Certification Medical Statement	Form
MRP Form 5-R Self-Certification Medical Statement MRP 5-R OCT 2017.pdf www.aphis.usda.gov/library/forms/pdf/mrp5_r.pdf	Form

IC Title:

Self Certification Medical Statement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 1630.14 5 CFR 339.203 5 CFR 339.204

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	MRP Form 5-R	Self-Certification Medical Statement	MRP 5-R OCT 2017.pdf	https://www.aphis.usda.gov/library/forms/pdf/mrp5_r.pdf	Yes	No	Fillable Printable

Line of Business: Natural Resources

Subfunction: Agricultural Innovation and Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 606

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	607	1	284	322
Annual IC Time Burden (Hours)	102	1	47	54
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
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.