Non-Insulin-Treated Diabetes Mellitus Assessment Form

OMB Control No:	ICR Reference No: 202306-2126-003
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOT/FMCSA	Agency Tracking No:
Title: Non-Insulin-Treated Diabetes Mellitus Assessment Form
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: 08/28/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	242,057	0
Time Burden (Hours)	32,274	0
Cost Burden (Dollars)	0	0

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Abstract: 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.

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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

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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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

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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

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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	242,057	0	0	0	242,057	0
Annual Time Burden (Hours)	32,274	0	0	0	32,274	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.

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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 [email protected]

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Common Form ICR:  No

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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: 08/28/2023

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