IC7 - Insulin-Treated Diabetes Mellitus Assessment Form

Medical Qualification Requirements

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2126-0006 can be found here:

Documents and Forms

Document Name Document Type
Form MCSA 5870 IC7 - Insulin-Treated Diabetes Mellitus Assessment Form Form
MCSA 5870 Insulin-Treated Diabetes Mellitus Assessment Form DRAFT ITDM Assessment Form.pdf Form

Information Collection (IC) Details

IC Title:	IC7 - Insulin-Treated Diabetes Mellitus Assessment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 49 CFR 391.41(b) 49 CFR 391.46

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	MCSA 5870	Insulin-Treated Diabetes Mellitus Assessment Form	DRAFT ITDM Assessment Form.pdf		Yes	Yes	Paper Only

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,906	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	4,906	4,906
Annual IC Time Burden (Hours)	654	654
Annual IC Cost Burden (Dollars)	60,416	60,416

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.