Information Collection

Self Certification Medical Statement

IC 2369 under ICR 202501-0579-003 · OMB 0579-0196.

Documents and Forms

Document Name Document Type
Form MRP Form 5 Self Certification Medical Statement Form
MRP Form 5 Self-Certification Medical Statement MRP 5 DEC 2020-ICR-FIL-508 (20250114).pdf Form
MRP Form 5 Self-Certification Medical Statement MRP 5 DEC 2020-ICR-FIL-508 (20250114).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Self Certification Medical Statement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 339.204 5 CFR 339.203 29 CFR 1630.14

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	MRP Form 5	Self-Certification Medical Statement	MRP 5 DEC 2020-ICR-FIL-508 (20250114).pdf		Yes	Yes	Fillable Printable

Line of Business: Natural Resources

Subfunction: Agricultural Innovation and Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 175	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	176	-433	609
Annual IC Time Burden (Hours)	31	-72	103
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.