Information Collection

391.41 CMV Driver Medication Form

IC 220971 under ICR 202302-2126-003 · OMB 2126-0064.

Documents and Forms

Documents and forms in this information collection
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 2-27-2021 508.pdf www.fmcsa.dot.gov/regulations/medical/39141-cmv-driver-medication-form-mcsa-5895-optional	Form and Instruction
MCSA 5895 391.41 CMV Driver Medication Form MCSA 5895 MCSA-5895 Form 2-27-2021 508.pdf www.fmcsa.dot.gov/regulations/medical/39141-cmv-driver-medication-form-mcsa-5895-optional	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 49 CFR 391.43 49 CFR 391.41

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 5895	391.41 CMV Driver Medication Form MCSA 5895	MCSA-5895 Form 2-27-2021 508.pdf	https://www.fmcsa.dot.gov/regulations/medical/39141-cmv-driver-medication-form-mcsa-5895-optional	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: 1,163,160

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,095,990	128,984	1,967,006
Annual IC Time Burden (Hours)	279,465	17,198	262,267
Annual IC Cost Burden (Dollars)	0	-27,396,411	27,396,411

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.