Information Collection

Report of Physical Examination

IC 262250 under ICR 202610-0648-005 · OMB 0648-0822.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NF 57-03-52 Report of Examination & Medical History - Diver Report of Physical Examination	Form
NF 57-03-52 Report of Examination & Medical History - Diver NF 57-03-52 Report of Examination and Medical History (1-25).pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Form	NF 57-03-52				Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: COMMERCE/NOAA-10 NOAA Diving Program File.

FR Citation: 72 FR 45009

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	11,700	11,700

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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