Information Collection

391.41 CMV Driver Medication Form

IC 220971 under ICR 201911-2126-001 · OMB 2126-0064.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2126-0064 can be found here:

Documents and Forms

Document Name Document Type
Form MCSA 5895 391.41 CMV Driver Medication Form Form and Instruction
MCSA 5895 391.41 CMV Driver Medication Form MCSA 5895 MCSA-5895 Form 4-7-2020 508.pdf www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/regulations/medical/83586/39141-cmv-driver-medication-form-mcsa-5895.pd Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	391.41 CMV Driver Medication Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 49 CFR 391.41 49 CFR 391.43

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	MCSA 5895	391.41 CMV Driver Medication Form MCSA 5895	MCSA-5895 Form 4-7-2020 508.pdf	https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/regulations/medical/83586/39141-cmv-driver-medication-form-mcsa-5895.pdf	Yes	Yes	Fillable Printable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records
Title: Privacy Act of 1974	FR Citation: 80 FR 73871

Number of Respondents: 1,223,470	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,967,006	884,806	1,082,200
Annual IC Time Burden (Hours)	262,267	117,974	144,293
Annual IC Cost Burden (Dollars)	27,396,411	12,268,733	15,127,678

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.