Information Collection

Documentation of medical fitness

IC 187967 under ICR 201009-1625-010 · OMB 1625-0079.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1625-0079 can be found here:

Documents and Forms

Document Name Document Type
1625-0079_Instructions.docx Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Documentation of medical fitness	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 46 CFR 12.02-17

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			1625-0079_Instructions.docx		Yes	Yes	Printable Only

Line of Business: Transportation

Subfunction: Water Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30,325	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 6 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	30,325	18,000	12,325
Annual IC Time Burden (Hours)	10,581	7,500	3,081
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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