Fire and Aviation Management Medical Qualifications Program

Forms and Documents

Document Name	Status
Form FS-5100-31 Fire and Aviation Medical Management Qualifications Program Form	Modified
30 day FRN 0596-0164.pdf Supplementary Document	2019-10-01
60 day FRN 0596-0164.pdf Supplementary Document	2019-10-01
0596-0164 Supporting Statement A_v06272019.docx Supporting Statement A	2019-06-27

IC Document Collections

IC ID	Document Title	Status
43556	Fire and Aviation Medical Management Qualifications Program Form	Modified

ICR Details

OMB Control No: 0596-0164	ICR Reference No: 201906-0596-003
Status: Active	Previous ICR Reference No: 201701-0596-002
Agency/Subagency: USDA/FS	Agency Tracking No:
Title: Fire and Aviation Management Medical Qualifications Program
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: 11/05/2019
	Date Received in OIRA: 06/27/2019
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2022	36 Months From Approved	11/30/2019
Responses	89,778	0	89,520
Time Burden (Hours)	10,488	0	10,289
Cost Burden (Dollars)	0	0	0

---

Abstract: Medical history, which is provided by completing the Health Screening Questionaire, Medical Qualifications Program Medical Exam and Self-Certification Statement supplies information needed to determine certification of suitability, any special medical or medication needs, and a file record to protect both the Federal Government and individuals.

---

Authorizing Statute(s): US Code: 16 USC 594 Name of Law: The Protection Act of 1922
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 17777	04/26/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 30690	06/27/2019
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Fire and Aviation Medical Management Qualifications Program	FS-5100-41, FS-5100-42, FS 5100-30, FS-5100-31	Health Screening Questionnaire ,   Work Capacity Test - Informed Consent ,   USFS Wildland Firefighter Medical Qualifications Program Physical Exam ,   Self Certification Statement and Blood Pressure Check

---

ICR Summary 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	89,778	89,520	0	258	0	0
Annual Time Burden (Hours)	10,488	10,289	0	199	0	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: There was an increase in participants.

---

Annual Cost to Federal Government: $229,053

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.     No

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

---

Common Form ICR:  No

---

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: 06/27/2019

---