Information Collection

Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872

IC 260909 under ICR 202306-2126-003 · OMB 2126-0081.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2126-0081 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form MCSA-5872 Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872	Form
MCSA-5872 Non-Insulin-Treated Diabetes Mellitus Assessment Form MCSA-5872 7-19-23 draft.pdf	Form
MCSA-5872 Non-Insulin-Treated Diabetes Mellitus Assessment Form MCSA-5872 7-19-23 draft.pdf	Form

IC Title:

Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 49 CFR 49 CFR Â§ 391.41(b)(1-13)

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	MCSA-5872	Non-Insulin-Treated Diabetes Mellitus Assessment Form	MCSA-5872 7-19-23 draft.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 242,057

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	242,057	242,057
Annual IC Time Burden (Hours)	32,274	32,274
Annual IC Cost Burden (Dollars)	0	0

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.