Information Collection

Pilot Medical Disclosure Survey IC

IC 276578 under ICR 202507-2120-005 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Informed Consent 20250721 th.docx	Other-Informed Consent
Informed Consent 20250721 th.docx	Other-Informed Consent
Pilot MDDM Survey.docx	Other-Survey Print Out
Pilot MDDM Survey_revised.docx	Other-

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Informed Consent				TBD	Yes	Yes	Fillable Fileable Signable
Other-					Yes	Yes	Printable Only

Line of Business: Transportation

Subfunction: Air Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,950

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,950	1,950
Annual IC Time Burden (Hours)	325	325
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.

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