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INSTRUCTIONS: Use this form when a single information collection document involves multiple reporting and recordkeeping requirements. The totals of the figures in cols. should be entered in item 13 of OMB-83-I: cols. (D) &/or (I) = 13a (respondent is only counted once); cols. F & I = 13b; cols. H & K = 13c. (F)Total/(D)Total = (E)Average (H)Total/(F)Total = (G)Average (K)Total/(I)Total = (J)Average
NOTE: The columns will calculate automatically. If Col. E's response is something other than annually, i.e., 1/6 years, list as "1/6" & decimal will display.
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TITLE OF INFORMATION COLLECTION DOCUMENT |
OMB NO. |
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| FIRE AND AVIATION MANAGEMENT MEDICAL QUALIFICATIONS PROGRAM |
0596-0164 |
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| DATE PREPARED |
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| IDENTIFICATION OF REPORTING OR RECORDKEEPING REQUIREMENT |
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ANNUAL BURDEN |
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REPORTS |
RECORDS |
RESPONDENT COST |
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TOTAL |
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FORMS NO (S) |
NO. OF |
NO OF |
TOTAL ANNUAL |
HOURS |
TOTAL |
NO. OF |
ANNUAL |
RECORD- |
COST |
TOTAL |
| SECTION OF |
DESCRIPTION |
(If "none" |
RESPONDENTS |
RESPONSES |
RESPONSES |
PER |
HOURS |
RECORD- |
HOURS PER |
KEEPING HOURS |
PER |
COST |
| REGS. |
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so state) |
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PER |
(Col. D x E) |
RESPONSE |
(Col. F x G) |
KEEPERS |
RECORD- |
(Col. I x J) |
HOUR |
(Col. H x L) |
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RESPONDENT |
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KEEPER |
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| (A) |
(B) |
(C) |
(D) |
(E) |
(F) |
(G) |
(H) |
(I) |
(J) |
(K) |
(L) |
(M) |
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Work Capacity Test Informed Consent |
FS-5100-30 |
24,400 |
1.00 |
24,400.00 |
0.090 |
2,196.00 |
0 |
0.000 |
0.00 |
16.20 |
$35,575.20 |
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Health Screening Questionnaire (Forest Service) |
FS-5100-31 |
24,400 |
1.00 |
24,400.00 |
0.170 |
4,148.00 |
0 |
0.000 |
0.00 |
16.20 |
$67,197.60 |
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Health Screening Questionnaire (Dept of Interior) |
FS-5100-31 |
900 |
1.0000 |
900.00 |
0.1700 |
153.00 |
0 |
0.000 |
0.00 |
16.20 |
$2,478.60 |
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Wildland Firefighter Medical Qualifications Program Medical Exam (future estimated) |
FS-5100-41 |
4,300 |
1.0000 |
4,300.00 |
3.0000 |
12,900.00 |
0 |
0.000 |
0.00 |
16.20 |
$208,980.00 |
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Self-Certification Statement and Bloos Pressure Check (future estimated) |
FS-5100-42 |
7,000 |
1.0000 |
7,000.00 |
0.1700 |
1,190.00 |
0 |
0.000 |
0.00 |
16.20 |
$19,278.00 |
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0.00 |
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0.00 |
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0.00 |
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$0.00 |
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SUBTOTAL |
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61,000.00 |
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20,587.00 |
0.00 |
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0.00 |
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$333,509.40 |
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TOTAL OF ALL PAGES |
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61,000.00 |
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20,587.00 |
0.00 |
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0.00 |
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$333,509.40 |
| TOTAL - COLUMNS "F" AND "I" = OMB 831, 13 b; COLUMNS "H" AND "K" = OMB 831, 13c |
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61,000.00 |
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20,587.00 |
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