Pilot Medical Disclosure Decision Making Model for Safety Risk Assessment Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
FAA-XXXX-Pilot Medical Disclosure Decision Making Survey-PTA 08.21.2025 AE.pdf	Supplementary Document	Uploaded 2026-01-09	Repair queued
FAA-XXXX-Pilot Medical Disclosure Decision Making Survey-PTA 08.21.2025 AE.pdf	Supplementary Document	Uploaded 2026-01-09	Available
Supporting Statement A Feb 2026.docx	Supporting Statement A	Uploaded 2026-02-04	Repair queued
Supporting Statement A Feb 2026.docx	Supporting Statement A	Uploaded 2026-02-04	Available
BTS PRAPartB Email Confirmation.pdf	Supplementary Document	Uploaded 2026-01-06	Available
BTS PRAPartB Email Confirmation.pdf	Supplementary Document	Uploaded 2026-01-06	Repair queued
Pilot Medical NonDisclosure Survey Final.docx	Supplementary Document	Uploaded 2025-12-30	Repair queued
Pilot Medical NonDisclosure Survey Final.docx	Supplementary Document	Uploaded 2025-12-30	Available
Supporting Statement Part B.docx	Supporting Statement B	Uploaded 2026-01-12	Repair queued
Supporting Statement Part B.docx	Supporting Statement B	Uploaded 2026-01-12	Available
Survey PTA 8202025.docx	Supplementary Document	Uploaded 2025-09-29	Repair queued
Survey PTA 8202025.docx	Supplementary Document	Uploaded 2025-09-29	Repair queued
Comment Matrix.docx	Supplementary Document	Uploaded 2025-09-15	Repair queued
Comment Matrix.docx	Supplementary Document	Uploaded 2025-09-15	Repair queued
60 days comments from ALPA FAA-2025-0562-0002_attachment_1.pdf	Public Comments	Uploaded 2025-08-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
276578	Pilot Medical Disclosure Survey IC	Other-Informed Consent	New

ICR Details

OMB Control No: 2120-0835	ICR Reference No: 202507-2120-005
Status: Active	Previous ICR Reference No:
Agency/Subagency: DOT/FAA	Agency Tracking No:
Title: Pilot Medical Disclosure Decision Making Model for Safety Risk Assessment Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/29/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/05/2026
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2029	36 Months From Approved
Responses	1,950	0	0
Time Burden (Hours)	325	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Office of Aerospace Medicine (AVS/AAM) is developing a pilot medical disclosure decision making model in to support current and future safety risk assessments. Following the Mental Health Aviation Rulemaking Committee's recommendation, AVS/AAM and the Office of Safety Standards (AFS) conducted a joint safety risk assessment on pilot medical non-disclosure. The assessment identified the need for a validated model of pilot medical disclosure decision-making to better estimate safety risks. A one-time, voluntary online survey will be administered using the Qualtrics platform. The survey includes 67 items and is expected to take up to 15 minutes to complete. All responses will remain confidential and reported in a manner that protects participant anonymity.

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Authorizing Statute(s): US Code: 5 USC 552a Name of Law: Privacy Act of 1976
   US Code: 44 USC Chapter 35 Name of Law: Paperwork Reduction Act (PRA)
   US Code: 49 USC 44516 Name of Law: Human factors program
  

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:
	90 FR 24487	06/10/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 1371	01/13/2026
Did the Agency receive public comments on this ICR? Yes

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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
Pilot Medical Disclosure Survey IC

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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	1,950	0	0	1,950	0	0
Annual Time Burden (Hours)	325	0	0	325	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: New ICR Summary of Burden. Previously at 0. Updated to show true ICR summary breakdown.

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Annual Cost to Federal Government: $51,430

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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.     No

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.     Yes

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: 02/05/2026

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