OMB control number
Self-Certification Medical Statement
OMB 0579-0196 ยท USDA/APHIS.
OMB 0579-0196
The purpose of this information collection is to obtain self-certification of physical ability from job applicants to determine their fitness and ability to perform strenuous duties related to jobs with demanding physical or environmental conditions.
The latest form for Self-Certification Medical Statement expires 2028-06-30 and is listed under ICR 202501-0579-003.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form MRP Form 5 Self-Certification Medical Statement | Form |
| Form MRP Form 5 Self Certification Medical Statement | Form |
| 0196 2025 Public Comment - Jean Public.msg.pdf (document unavailable) | Public Comments |
 0196 2025 APHIS 79 (20250114).xlsx | Supplementary Document |
| 0196 2025 APHIS 79 (20250114).xlsx | Supplementary Document |
| 0196 2025 APHIS 71 (20250114).xlsx | Supplementary Document |
| 0196 2025 APHIS 71 (20250114).xlsx | Supplementary Document |
 0196 2024 SS (20250219).docx | Supporting Statement A |
| 0196 2024 SS (20250219).docx | Supporting Statement A |
 Self Certification Medical Statement |
Form |
| Self Certification Medical Statement |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202501-0579-003 | Revision of a currently approved collection | 2025-02-20 | ||
| 202103-0579-003 | Revision of a currently approved collection | 2021-03-19 | Approved without change | |
| 202012-0579-010 | No material or nonsubstantive change to a currently approved collection | 2021-01-04 | ||
| 201801-0579-005 | Revision of a currently approved collection | 2018-02-22 | Approved without change | |
| 201412-0579-001 | Revision of a currently approved collection | 2014-12-16 | Approved without change | |
| 201110-0579-007 | Revision of a currently approved collection | 2011-11-02 | Approved without change | |
| 200710-0579-002 | Revision of a currently approved collection | 2008-05-23 | Approved without change | |
| 200504-0579-003 | Extension without change of a currently approved collection | 2005-04-13 | Approved without change | |
| 200204-0579-002 | New collection (Request for a new OMB Control Number) | 2002-04-25 | Approved without change |