View Information Collection Request (ICR) Package
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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:
2126-0081
ICR Reference No:
202507-2126-011
Status:
Active
Previous ICR Reference No:
202306-2126-003
Agency/Subagency:
DOT/FMCSA
Agency Tracking No:
Ready for OST review of non-sub change request.
Title:
Non-Insulin-Treated Diabetes Mellitus Assessment Form
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
12/05/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
09/22/2025
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2027
01/31/2027
01/31/2027
Responses
242,057
0
242,057
Time Burden (Hours)
32,274
0
32,274
Cost Burden (Dollars)
0
0
0
Abstract:
This is a non-substantive change request to update the form no. MCSA-5872, "Non-Insulin-Treated Diabetes Mellitus Assessment Form" with the correct expiration date. FMCSA seeks the Office of Management and Budget’s (OMB) approval of a new ICR titled, Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872. This ICR is voluntary and may be utilized by medical examiners (ME), who issue Medical Examiner’s Certificates, Form MCSA-5876, to individuals who operate commercial motor vehicles (CMV) in interstate commerce, to communicate with treating healthcare providers responsible for managing the individuals’ diagnosed non-insulin-treated diabetes mellitus. The purpose of the Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872, is to assist the ME in determining whether an individual diagnosed with non-insulin-treated diabetes mellitus is physically qualified and the individual’s physical condition is adequate to enable the individual to operate a CMV safely. Because this collection is voluntary, there is no set schedule for CMV operators or MEs to complete the form MCSA-5872. FMCSA estimates that MEs will request that forms be completed for 242,057 individuals with a corresponding number of treating healthcare providers.
Authorizing Statute(s):
US Code:
49 USC §§ 31502(b)
Name of Law: Motor Carrier Safety
US Code:
49 USC §§ 31136
Name of Law: Commercial Motor Vehicle Safety
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:
88 FR 22517
04/13/2023
30-day Notice:
Federal Register Citation:
Citation Date:
88 FR 58061
08/24/2023
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
Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872
MCSA-5872
Non-Insulin-Treated Diabetes Mellitus Assessment Form
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
242,057
242,057
0
0
0
0
Annual Time Burden (Hours)
32,274
32,274
0
0
0
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:
This is a new ICR therefore there is a burden increase.
Annual Cost to Federal Government:
$0
Does this IC contain surveys, censuses, or employ statistical methods?
No
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.
Yes
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:
Christine Hydock 202 366-1220 christine.hydock@dot.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:
09/22/2025
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