View Information Collection Request (ICR) Package
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View ICR - Agency Submission
COMMENT
Time Remaining
Days
HR
Min
Sec
OMB Control No:
ICR Reference No:
202507-2120-005
Status:
Received in OIRA
Previous ICR Reference No:
Agency/Subagency:
DOT/FAA
Agency Tracking No:
Title:
Pilot Medical Disclosure Decision Making Model for Safety Risk Assessment Survey
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Regular
Date Submitted to OIRA:
02/05/2026
Requested
Previously Approved
Expiration Date
36 Months From Approved
Responses
1,950
0
Time Burden (Hours)
325
0
Cost Burden (Dollars)
0
0
Abstract:
The Office of Aerospace Medicine (AVS/AAM) is developing a pilot medical disclosure decision making model in to support current and future safety risk assessments. Following the Mental Health Aviation Rulemaking Committee's recommendation, AVS/AAM and the Office of Safety Standards (AFS) conducted a joint safety risk assessment on pilot medical non-disclosure. The assessment identified the need for a validated model of pilot medical disclosure decision-making to better estimate safety risks. A one-time, voluntary online survey will be administered using the Qualtrics platform. The survey includes 67 items and is expected to take up to 15 minutes to complete. All responses will remain confidential and reported in a manner that protects participant anonymity.
Authorizing Statute(s):
US Code:
5 USC 552a
Name of Law: Privacy Act of 1976
US Code:
44 USC Chapter 35
Name of Law: Paperwork Reduction Act (PRA)
US Code:
49 USC 44516
Name of Law: Human factors program
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:
90 FR 24487
06/10/2025
30-day Notice:
Federal Register Citation:
Citation Date:
91 FR 1371
01/13/2026
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Pilot Medical Disclosure Survey IC
ICR Summary of Burden
Total Request
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
1,950
0
0
1,950
0
0
Annual Time Burden (Hours)
325
0
0
325
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
New ICR Summary of Burden. Previously at 0. Updated to show true ICR summary breakdown.
Annual Cost to Federal Government:
$51,430
Does this IC contain surveys, censuses, or employ statistical methods?
Yes
Part B of Supporting Statement
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
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?
No
Agency Contact:
Tammy Ho 405 954-0334 tammy.t.ho@faa.gov
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:
02/05/2026
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