Information Collection

Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872

IC 260909 under ICR 202306-2126-003 · OMB 2126-0081.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2126-0081 can be found here:

Documents and Forms

Document Name Document Type
Form MCSA-5872 Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872 Form
MCSA-5872 Non-Insulin-Treated Diabetes Mellitus Assessment Form MCSA-5872 7-19-23 draft.pdf Form
MCSA-5872 Non-Insulin-Treated Diabetes Mellitus Assessment Form MCSA-5872 7-19-23 draft.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 49 CFR 49 CFR Â§ 391.41(b)(1-13)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	MCSA-5872	Non-Insulin-Treated Diabetes Mellitus Assessment Form	MCSA-5872 7-19-23 draft.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 242,057	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	242,057	242,057
Annual IC Time Burden (Hours)	32,274	32,274
Annual IC Cost Burden (Dollars)	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.