Information Collection

USM-522A Physician Evaluation Report for USMS Operational Employees

IC 205737 under ICR 201911-1105-001 · OMB 1105-0099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1105-0099 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form USM-522A USM-522A Physician Evaluation Report for USMS Operational Employees	Form and Instruction
USM-522A Physician Evaluation Report for USMS Operational Employe usm522a-20200120.pdf	Form and Instruction

IC Title:

USM-522A Physician Evaluation Report for USMS Operational Employees

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	USM-522A	Physician Evaluation Report for USMS Operational Employees	usm522a-20200120.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: OPM/GOVT-10, Employee Medical File System Records

FR Citation: 65 FR 24732

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	700	700
Annual IC Cost Burden (Dollars)	56,700	56,700

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.