Information Collection

Pre-Employment Medical and Driver Medical Evaluation Forms

IC 270045 under ICR 202408-1405-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-6571 Pre-Employment Medical and Driver Medical Evaluation Forms	Form and Instruction
DS-6571 Med Eval for LES non-drivers ds6571 - DRAFT - 03-20-2024.pdf	Form and Instruction
DS-6572 Driver Medical Eval for LES ds6572 - DRAFT - 04-10-2024.pdf	Form and Instruction
DS-6573 TB Risk Assessment ds6573 - DRAFT - 03-21-2024.pdf	Form and Instruction
DS-6574 Seizure/Epilepsy ds6574 - DRAFT - 03-20-2024.pdf	Form and Instruction
DS-6575 Diabetes ds6575 - DRAFT - 03-20-2024.pdf	Form and Instruction
DS-6576 USDH Driver ds6576 - DRAFT - 03-20-2024.pdf	Form and Instruction
DS-6577 Vision Assessment ds6577 - DRAFT - 03-20-2024.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	DS-6571	Med Eval for LES non-drivers	ds6571 - DRAFT - 03-20-2024.pdf	No	Paper Only
Form and Instruction	DS-6572	Driver Medical Eval for LES	ds6572 - DRAFT - 04-10-2024.pdf	No	Paper Only
Form and Instruction	DS-6573	TB Risk Assessment	ds6573 - DRAFT - 03-21-2024.pdf	No	Paper Only
Form and Instruction	DS-6574	Seizure/Epilepsy	ds6574 - DRAFT - 03-20-2024.pdf	No	Paper Only
Form and Instruction	DS-6575	Diabetes	ds6575 - DRAFT - 03-20-2024.pdf	No	Paper Only
Form and Instruction	DS-6576	USDH Driver	ds6576 - DRAFT - 03-20-2024.pdf	No	Paper Only
Form and Instruction	DS-6577	Vision Assessment	ds6577 - DRAFT - 03-20-2024.pdf	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Pre-Employment Medical and Driver Medical Evaluation Forms

FR Citation: 89 FR 45726

Number of Respondents: 13,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	13,000	13,000
Annual IC Time Burden (Hours)	34,550	34,550
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.