Certificate of Medical Examination

ICR 200810-3206-010

OMB: 3206-0250

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
New
Supplementary Document
2008-12-12
Supplementary Document
2008-10-29
Supplementary Document
2008-10-29
Supplementary Document
2008-10-29
Supporting Statement A
2008-10-29
IC Document Collections
ICR Details
3206-0250 200810-3206-010
Historical Active
OPM
Certificate of Medical Examination
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 02/13/2009
Retrieve Notice of Action (NOA) 12/12/2008
  Inventory as of this Action Requested Previously Approved
02/29/2012 36 Months From Approved
45,000 0 0
135,000 0 0
0 0 0

The medical information to be collected using Optional Form (OF) XX, Certificate of Medical Exmination, a revision of Standard Form (SF) F78, which was last revised in October 1969, is needed to determine whether an incumbent or applicant for a Federal position which requires physical fitness/agility testing and/or medical examinations as a condition of employment meets the physical requirements of the position, to ensure fair and consistent treatment of employees and job applicants and to adjudicate passover of a preference eligible and claims of discrimination under the Americans with Disabilities Act (ADA).

US Code: 5 USC 3312 Name of Law: Veteran Preference Rights
   US Code: 5 USC 3318 Name of Law: Competitive Service; Selection from certificates
   US Code: 5 USC 3504 Name of Law: null
  
None

Not associated with rulemaking

  71 FR 76377 12/20/2006
73 FR 49223 08/20/2008
No

1
IC Title Form No. Form Name
Certificate of Medical Examination OF XX Certificate of Medical Examination

  Total Approved 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 45,000 0 0 45,000 0 0
Annual Time Burden (Hours) 135,000 0 0 135,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new collection of information.

$127,182
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Susan Spannbauer 202 606-0292 susan.spannbauer@opm.gov

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
12/12/2008


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