Fire and Aviation Management Medical Qualifications Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FS-5100-42 Self Certification Statement	Form	Modified	Available
Form FS-5100-41 Essential Function & Work Conditions	Form	Modified	Available
Form FS-5100-31 Health Screening Questionnaire	Form	Modified	Available
Form FS-5100-30 Informed Consent	Form	Modified	Available
Form FS-5100-30 Fire and Aviation Medical Management Qualifications Program	Form	Modified	Repair queued
0596-0164 Fire and Aviation Management Medical Qualifications Program Justification for a Non-Substantive Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-01-23	Available
0596-0164 Fire and Aviation Management Medical Qualifications Program Justification for a Non-Substantive Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-01-23	Available
0596-0164 -- Burden-cost Spreadsheet.Final_sem.xlsm	Supplementary Document	Uploaded 2022-11-03	Repair queued
0596-0164 -- Burden-cost Spreadsheet.Final_sem.xlsm	Supplementary Document	Uploaded 2022-11-03	Repair queued
0596-0164 Supporting Statement A_Final_SEM.docx	Supporting Statement A	Uploaded 2022-11-03	Available
0596-0164 Supporting Statement A_Final_SEM.docx	Supporting Statement A	Uploaded 2022-11-03	Repair queued
Burden Hour Revision Justification 2022.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-05-18	Available
Burden Hour Revision Justification 2022.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-05-18	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43556	Fire and Aviation Medical Management Qualifications Program	Form	Modified	Self Certification Statement
43556	Fire and Aviation Medical Management Qualifications Program	Form	Modified	Essential Function & Work Conditions
43556	Fire and Aviation Medical Management Qualifications Program	Form	Modified	Health Screening Questionnaire
43556	Fire and Aviation Medical Management Qualifications Program	Form	Modified	Informed Consent
43556	Fire and Aviation Medical Management Qualifications Program	Form	Modified

ICR Details

OMB Control No: 0596-0164	ICR Reference No: 202501-0596-002
Status: Historical Active	Previous ICR Reference No: 202201-0596-006
Agency/Subagency: USDA/FS	Agency Tracking No:
Title: Fire and Aviation Management Medical Qualifications Program
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/14/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/23/2025
Terms of Clearance: Non-sub change approved. Please submit for renewal in 2026.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2026	06/30/2026	06/30/2026
Responses	61,000	0	61,000
Time Burden (Hours)	20,587	0	20,587
Cost Burden (Dollars)	0	0	0

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Abstract: Medical history, which is provided by completing the Health Screening Questionaire, Medical Qualifications Program Medical Exam and Self-Certification Statement supplies information needed to determine certification of suitability, any special medical or medication needs, and a file record to protect both the Federal Government and individuals.

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Authorizing Statute(s): US Code: 16 USC 594 Name of Law: The Protection Act of 1922
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 8783	02/16/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 71570	11/23/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Fire and Aviation Medical Management Qualifications Program	FS-5100-41, FS-5100-30, FS-5100-31, FS-5100-42	Informed Consent ,   Health Screening Questionnaire ,   Essential Function & Work Conditions ,   Self Certification Statement

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	61,000	61,000	0	0	0	0
Annual Time Burden (Hours)	20,587	20,587	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $229,053

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/23/2025

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