Information Collection

IC6 - Medical Examiner's Certification Integration Final Rule

IC 220813 under ICR 202007-2126-001 · OMB 2126-0006.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form MCSA-5875 IC6 - Medical Examiner's Certification Integration Final Rule	Form and Instruction
MCSA-5875 Medical Examination Report Form Revised MCSA-5875 7-5-20 508.pdf www.fmcsa.dot.gov/	Form and Instruction
MCSA-5876 Medical Examiner's Certificate Revised Medical Examiner's Certificate Form MCSA-5876.pdf www.fmcsa.dot.gov/	Form
PRA-2126-0006 Justification NonSubstantive Change to MCSA-5875 031920.docx Justification for Nonsubstantive Change to MCSA-5875	IC Document
Justification of Non-substantive Changes for MCSA-5875 07.08.20.docx Justification for Nonsubstantive Change to MCSA-5875 07.08.20	IC Document

IC Title:

IC6 - Medical Examiner's Certification Integration Final Rule

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 49 CFR 391.43

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	MCSA-5875	Medical Examination Report Form Revised	MCSA-5875 7-5-20 508.pdf	https://www.fmcsa.dot.gov/	Yes	Yes	Fillable Fileable Signable
Form	MCSA-5876	Medical Examiner's Certificate Revised	Medical Examiner's Certificate Form MCSA-5876.pdf	https://www.fmcsa.dot.gov/	Yes	Yes	Fillable Fileable Signable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification for Nonsubstantive Change to MCSA-5875	PRA-2126-0006 Justification NonSubstantive Change to MCSA-5875 031920.docx	04/22/2020
Justification for Nonsubstantive Change to MCSA-5875 07.08.20	Justification of Non-substantive Changes for MCSA-5875 07.08.20.docx	07/08/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.