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OMB NO.
TITLE OF INFORMATION COLLECTION DOCUMENT
0579-0196
Self-Certification Medical Statement
DATE PREPARED
September 13, 2017
ANNUAL BURDEN
IDENTIFICATION OF REPORTING OR RECORDKEEPING REQUIREMENT
REPORTS
SECTION OF REGS
(TITLE 9, CFR)
DESCRIPTION
FORM NO's
(if none, so
state)
NO. OF
RESPONDENTS
NO. OF
RESPONSES PER
RESPONDENT
(A)
(B)
(C)
(D)
(E)
RECORDS
TOTAL ANNUAL
RESPONSES
HOURS PER
RESPONSE
(Col. D x E)
5 CFR 339.203;
29 CFR 1630.14
Self-Certification Medical Statement (Individual)
5 CFR 339.204
Request for Waiver of Standards and
Requirements (Individual)
MRP 5
none
TOTAL HOURS
COLUMNS H + K = OMB 831, 13c
ANNUAL HOURS
PER RECORDKEEPER
(I)
(J)
(Col. F x G)
(F)
(G)
RECORDKEEPING
HOURS
(Col. I x J)
(H)
(K)
606
1
606
0.167
101
0
0.000
0
1
1
1
1.000
1
0
0.000
0
SUBTOTAL
607
102
0
0
TOTAL OF ALL PAGES
607
102
0
0
607
102
TOTAL
COLUMNS F + I = OMB 831, 13b
NO. OF
RECORDKEEPERS
| File Type | application/pdf |
| Author | cquatrano |
| File Modified | 2018-01-23 |
| File Created | 2018-01-23 |