Information Collection

Passenger (3rd Party Disclosure) - Informed Consent and Medical Certification with no pre-existing conditions) for Simulated Voyage

IC 246888 under ICR 202110-0920-007 · OMB 0920-1335.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1335 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ROCIS - Informed Consent Medical Cert.docx	Instruction
Attachment S_Informed Consent and Medical Certification for Simulated Voyage.docx	Instruction

IC Title:

Passenger (3rd Party Disclosure) - Informed Consent and Medical Certification with no pre-existing conditions) for Simulated Voyage

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
Instruction			ROCIS - Informed Consent Medical Cert.docx		Yes	Yes	Fillable Fileable
Instruction			Attachment S_Informed Consent and Medical Certification for Simulated Voyage.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18,000

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	18,000	-21,000	39,000
Annual IC Time Burden (Hours)	4,500	-44,250	48,750
Annual IC Cost Burden (Dollars)	736,200	-858,900	1,595,100

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.