Self-Certification Medical Statement

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 2021-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form MRP Form 5 Self Certification Medical Statement Form
0196 2021 SS (20210318).docx Supporting Statement A
0196 2021 79 (20210318).xlsx Supplementary Document
0196 2021 71 (20210318).xlsx Supplementary Document
Self Certification Medical Statement Form

All Historical Document Collections

202103-0579-003 Approved without change	Revision of a currently approved collection	2021-03-19
202012-0579-010	No material or nonsubstantive change to a currently approved collection	2021-01-04
201801-0579-005 Approved without change	Revision of a currently approved collection	2018-02-22
201412-0579-001 Approved without change	Revision of a currently approved collection	2014-12-16
201110-0579-007 Approved without change	Revision of a currently approved collection	2011-11-02
200710-0579-002 Approved without change	Revision of a currently approved collection	2008-05-23
200504-0579-003 Approved without change	Extension without change of a currently approved collection	2005-04-13
200204-0579-002 Approved without change	New collection (Request for a new OMB Control Number)	2002-04-25