View Information Collection (IC)

View Information Collection (IC)

IC Title:	IC6 - Medical Examiner's Certification Integration Final Rule	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 49 CFR 391.43

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	MCSA-5875	Medical Examination Report Form Revised	MCSA-5875 7-5-20 508.pdf	https://www.fmcsa.dot.gov/	Yes	Yes	Fillable Fileable Signable
Form	MCSA-5876	Medical Examiner's Certificate Revised	Medical Examiner's Certificate Form MCSA-5876.pdf	https://www.fmcsa.dot.gov/	Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	1	0	0	0	0	1
Annual IC Time Burden (Hours)	0	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Justification for Nonsubstantive Change to MCSA-5875	PRA-2126-0006 Justification NonSubstantive Change to MCSA-5875 031920.docx	04/22/2020
Justification for Nonsubstantive Change to MCSA-5875 07.08.20	Justification of Non-substantive Changes for MCSA-5875 07.08.20.docx	07/08/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.