View Information Collection Request (ICR) Package
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View Information Collection (IC) List
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0579-0196
ICR Reference No:
201110-0579-007
Status:
Historical Active
Previous ICR Reference No:
200710-0579-002
Agency/Subagency:
USDA/APHIS
Agency Tracking No:
Title:
Self - Certification Medical Statement
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
12/20/2011
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/02/2011
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2014
36 Months From Approved
12/31/2011
Responses
524
0
600
Time Burden (Hours)
88
0
100
Cost Burden (Dollars)
0
0
0
Abstract:
The purpose of this collection is to obtain medical information regarding the employment decisions for a job applicant.
Authorizing Statute(s):
None
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
5 FR 339
07/01/2011
30-day Notice:
Federal Register Citation:
Citation Date:
76 FR 207
10/26/2011
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Self Certification Medical Statement
MRP-5
Self - Certification Medical Statement
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
524
600
0
0
-76
0
Annual Time Burden (Hours)
88
100
0
0
-12
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
In the previous collection there were 600 respondents, 600 responses, and 100 burden hours, due to an adjustment decrease in respondents to 524 this reduced the number of respondents and responses to 524 a difference of 76, and the number of burden hours to 88 reducing the total burden hours by 12. The adjusted decrease is due to a decrease in the number of respondents who complete the Self-Certification Medical Statement annually.
Annual Cost to Federal Government:
$3,281
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Eric Williams 612 336-3370
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
11/02/2011
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