Information Collection

Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical

IC 43932 under ICR 201409-1625-011 · OMB 1625-0040.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1625-0040 can be found here:

Documents and Forms

Document Name Document Type
Form CG-719B Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical Form and Instruction
1625-0040_Instruction_r0_23Jan2014.docx Instruction
CG-719K (01/14) Application for Merchant Mariner Medical Certificate CG-719K CG vendor version_13Mar14.pdf www.uscg.mil/forms Form and Instruction
CG-719K/E (01/14) Application for Merchant Mariner Medical Certificate for CG-719KE CG vendor version_12Mar14.pdf www.uscg.mil/forms Form and Instruction
CG-719P (01/14) DOT/USCG Periodic Drug Testing Form CG-719P CG vendor version_14Feb14.pdf www.uscg.mil/forms Form and Instruction
CG-719S (01/14) Small Vessel Sea Service Form CG-719S CG vendor version_11Feb14.pdf www.uscg.mil/forms Form and Instruction
CG-719C (01/14) Disclosure Statement for Narcotics, DWI/DUI, AND/OR Othe CG-719C CG vendor version_14Feb14.pdf www.uscg.mil/forms Form and Instruction
CG-719B Application for Merchant Mariner Credential (MMC) CG-719B CG vendor version_12Mar14.pdf www.uscg.mil/forms Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical	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 10.105(b)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CG-719B	Application for Merchant Mariner Credential (MMC)	CG-719B CG vendor version_12Mar14.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Instruction			1625-0040_Instruction_r0_23Jan2014.docx		Yes	Yes	Printable Only
Form and Instruction	CG-719K (01/14)	Application for Merchant Mariner Medical Certificate	CG-719K CG vendor version_13Mar14.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719K/E (01/14)	Application for Merchant Mariner Medical Certificate for Entry Level Ratings	CG-719KE CG vendor version_12Mar14.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719P (01/14)	DOT/USCG Periodic Drug Testing Form	CG-719P CG vendor version_14Feb14.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719S (01/14)	Small Vessel Sea Service Form	CG-719S CG vendor version_11Feb14.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable
Form and Instruction	CG-719C (01/14)	Disclosure Statement for Narcotics, DWI/DUI, AND/OR Other Convictions	CG-719C CG vendor version_14Feb14.pdf	http://www.uscg.mil/forms	Yes	Yes	Fillable Printable

Line of Business: Transportation

Subfunction: Water Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 259,606	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	56,500	0	56,500
Annual IC Time Burden (Hours)	47,444	3,186	44,258
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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