0579-0196 2018 Ss

February 2018
Supporting Statement
Self-Certification Medical Statement
OMB No. 0579-0196

1. Explain the circumstances that make the collection of information necessary. Identify any legal
or administrative requirements that necessitate the collection.
The Marketing and Regulatory Programs (MRP) agencies of the U.S. Department of Agriculture
facilitates the domestic and international marketing of U.S. agricultural products and protecting the health
of domestic animal and plant resources. These agencies are the Animal and Plant Health Inspection
Service (APHIS); the Agricultural Marketing Service; and the Grain Inspection, Packers and Stockyards
Administration. Resource management and administrative services, including human resource
management, for the three MRP agencies are provided by the APHIS MRP Business Services unit.
MRP agencies are authorized by 5 CFR 339 and 29 CFR 1630 to obtain medical information from
applicants for positions that have approved medical standards due to duties that are arduous or hazardous,
or require a certain level of health status or fitness. These agencies have positions with duties that extend
beyond sedentary and require specific medical standards and/or physical requirements to perform
successfully and safely. The medical qualifications standards for appointment to the covered positions
listed in the MRP Medical Examination Requirements Charts are justified on the basis that the duties are
arduous or hazardous, require a certain level of health status and fitness, and the nature of the positions
involves a high degree of responsibility toward the public.
This information collection is necessary for making a preliminary determination regarding a candidate’s
physical fitness and ability to perform the duties of a covered position. MRP uses the Self-Certification
Medical Statement (MRP Form 5-R) for positions requiring verification of fitness, and applicants may
also submit a request for waiver of standards and requirements. Inability to collect this information
would adversely affect the MRP agencies' ability to make employment decisions and determinations
regarding an applicant's physical fitness to safely and efficiently perform assigned duties.
APHIS is asking OMB to approve, for an additional 3 years, its use of these information collection
activities to collect physical fitness certification from job applicants for positions requiring a certain level
of health status and fitness.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new
collection, indicate the actual use the agency has made of the information received from the current
collection.
The APHIS Human Resources Division (HRD) uses the following information collection activities to
make preliminary determinations regarding candidates’ physical fitness and ability to perform duties of
covered positions.
Self-Certification Medical Statement (MRP Form 5-R) (5 CFR 339.203, 29 CFR 1630.14)
(Individual) - This form is completed by the job applicant and contains a series of YES or NO questions
for self-assessing his/her physical limitations, and physical and environmental endurance factors. A
Human Resources specialist uses the information to make a preliminary determination regarding the
candidate’s physical fitness and ability to perform the duties of a covered position.

Request for Waiver of Standards and Requirements (5 CFR 339.204) (Individual)

If the Agency determines that an applicant may not meet the physical/medical standards of a
covered position as a result of responses to the MRP 5 questionnaire, it may consider additional
documentation submitted by the applicant to determine the individual’s ability to perform the
duties of the job. A job applicant may submit a request for waiver for a medical standard or physical
requirement if he/she is unable to meet that standard or requirement and presents sufficient evidence that
he/she, with or without reasonable accommodation, can perform the essential duties of the position
without endangering the health and safety of the applicant or others.

3. Describe whether, and to what extent, the collection of information involves the use of
automated, electronic, mechanical, or other technological collection techniques or other forms of
information technology, e.g., permitting electronic submission of responses, and the basis for the
decision for adopting this means of collection. Also describe any consideration of using information
technology to reduce burden.
The Self-Certification Medical Statement (MRP Form 5-R) is in fillable PDF format and may be
completed digitally. However, it must be printed and signed by the applicant. In the last request for
renewal approval, APHIS HRD indicated the MRP-5 might be included in HRD’s automated Enter on
Duty (EOD) initiative. HRD has since decided to limit EOD to new hires. The MRP Form 5-R is a prehire activity and will not be automated beyond a fillable PDF at this time.
The Request for Waiver of Standards and Requirements is prepared by the applicant. There is no
prescribed format for its submission.

4. Describe efforts to identify duplication. Show specifically why any similar information already
available cannot be used or modified for use for the purposes described in Item 2 above.
The information collected by the MRP Form 5-R, or submitted in a waiver request, is specific to MRP
agency positions and is not available from or requested by any other source.

5. If the collection of information impacts small businesses or other small entities, describe any
methods used to minimize burden.
All respondents are private individuals. There are no small businesses or entities associated with this
information collection request.

6. Describe the consequences to Federal program or policy activities if the collection is not
conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing
burden.
If this collection were not conducted, MRP would not be able to determine the fitness of job applicants
for certain positions within its agencies. Consequently, an Agency may inadvertently appoint an
individual to a position for which he or she is medically unsuitable to perform, creating hazardous
working conditions for the new employee and associated co-workers. This information is collected only
once during the application process.

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7. Explain any special circumstances that would cause an information collection to be conducted in
a manner:
•

requiring respondents to report information to the agency more often than quarterly;

•

requiring respondents to prepare a written response to a collection of information in fewer
than 30 days after receipt of it;

•

requiring respondents to submit more than an original and two copies of any document;

•

requiring respondents to retain records, other than health, medical, government contract,
grant-in-aid, or tax records for more than three years;

•

in connection with a statistical survey, that is not designed to produce valid and reliable
results that can be generalized to the universe of study;

•

requiring the use of a statistical data classification that has not been reviewed and approved
by OMB;

•

that includes a pledge of confidentiality that is not supported by authority established in
statute or regulation, that is not supported by disclosure and data security policies that are
consistent with the pledge, or which unnecessarily impedes sharing of data with other
agencies for compatible confidential use; or

•

requiring respondents to submit proprietary trade secret, or other confidential information
unless the agency can demonstrate that it has instituted procedures to protect the
information's confidentiality to the extent permitted by law.

No special circumstances exist that would require this information collection to be conducted in a manner
inconsistent with the general information collection guidelines in 5 CFR 1320.5.

8. Describe efforts to consult with persons outside the agency to obtain their views on the
availability of data, frequency of collection, the clarity of instructions and recordkeeping,
disclosure, or reporting form, and on the data elements to be recorded, disclosed, or reported. If
applicable, provide a copy and identify the date and page number of publication in the Federal
Register of the agency's notice, soliciting comments on the information collection prior to
submission to OMB.
Dr. Thomas R. Walker, MD
Branch Chief, Safety Health and Environmental Protection Branch
Emergency Management, Safety, and Security Division
USDA Marketing and Regulatory Programs
tel. (301) 436-3145
email [email protected]
Ms. Christy Pankey
Agricultural Commodity Grader (recent hire)
USDA Agricultural Marketing Service
tel. (804) 548-6668
email [email protected]

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Mr. Juan Galicia
Agricultural Commodity Grader (recent hire)
USDA Agricultural Marketing Service
tel. (859) 213-1447
email [email protected]
Mr. Thaddeus Davis
Agricultural Commodity Grader (recent hire)
USDA Agricultural Marketing Service
tel. (863) 294-7416
email [email protected]
On Tuesday, November 21, 2017, APHIS published in the Federal Register on pages 55344 and 55345 a
60-day notice seeking public comments on its plans to request a 3-year renewal of this collection of
information. No comments from the public were received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of
contractors or grantees.
This information collection activity involves no payments or gifts to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the
assurance in statute, regulation, or agency policy.
No additional assurance of confidentiality is provided with this information collection. However, the
confidentiality of information is protected under 5 U.S.C. 552a.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior
or attitudes, religious beliefs, and other matters that are commonly considered private. This
justification should include the reasons why the agency considers the questions necessary, the
specific uses to be made of the information, the explanation to be given to persons from whom the
information is requested, and any steps to be taken to obtain their consent.
Personal medical information provided by a job applicant respondent is required by APHIS hiring
officials to assess the applicant’s physical fitness. Other personally identifiable information is collected
to identify the applicant. The assessment determines if a medical condition exists which impedes the
applicant’s ability to efficiently perform the essential functions of a covered position without hazard to
the employee or others. The form’s purpose is built into its instructions, and it contains a Privacy Act
statement.

12. Provide estimates of the hour burden of the collection of information. Indicate the number of
respondents, frequency of response, annual hour burden, and an explanation of how the burden
was estimated.
See APHIS Form 71.

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● Provide estimates of annualized cost to respondents for the hour burdens for collections of
information, identifying and using appropriate wage rate categories.
APHIS estimates the total annualized cost to respondents to be $2,434. Respondents are private
individuals applying for jobs within the USDA. APHIS arrived at this cost figure by multiplying the
respondents’ $23.86 mean hourly wage by the 102 burden hours in this information collection request.
The mean hourly wage for all occupations was derived from U.S. Department of Labor Bureau of Labor
Statistics website at https://www.bls.gov/news.release/pdf/ocwage.pdf.

13. Provide estimates of the total annual cost burden to respondents or record keepers resulting from
the collection of information (do not include the cost of any hour burden shown in Items 12 and 14).
No annual cost burden is associated with capital and startup costs, operation and maintenance
expenditures, and purchase of services.

14. Provide estimates of annualized cost to the Federal Government. Provide a description of the
method used to estimate cost and any other expense that would not have been incurred without this
collection of information.
See APHIS Form 79. The estimated annualized cost to the Federal Government is $4,082.
15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the
0MB Form 83-I.

Requested
Annual Number of
Responses
Annual Time
Burden (Hours)

Program
Change Due to Change Due to
Program
Change Due to Adjustment in
Potential
Change Due to
Agency
Agency
Violation of the
New Statute
Discretion
Estimate
PRA

Previously
Approved

607

0

1

284

0

322

102

0

1

47

0

54

All of the respondents in this information collection are private individuals. In this renewal, their number
increased from 322 to 606. The number of annual responses changed from 322 to 607 for a net increase
of 285 responses, and the total burden hours changed from 54 to 102 for a net increase of 48 hours.
All but one of the increases are attributed to estimate adjustments reflecting the current number of
respondents. A new burden, Request for Waiver of Standards and Requirements, was identified in the
CFR and added, increasing the total figures by 1 response and 1 hour of burden.

16. For collections of information whose results are planned to be published, outline plans for
tabulation and publication.
APHIS has no plans to publish information it collects in connection with this program.

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17. If seeking approval to not display the expiration date for 0MB approval of the information
collection, explain the reasons that display would be inappropriate.
APHIS will display the OMB approval expiration date on the MRP Form 5-R.

18. Explain each exception to the certification statement identified in Item 19 “Certification for
Paperwork Reduction Act.”
APHIS can certify compliance with all provisions in the Act.

B. Collections of Information Employing Statistical Methods
There are no statistical methods associated with the information collection activities used in this program.

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