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

Application for Merchant Mariner Credential (MMC), Merchant Mariner Certificate Evaluation Report, Small Vessel Sea Service Form, DOT/USCG Periodic Drug Testing Form, Merchant Mariner Evaluation of Fi

⚠️ Notice: This information collection may be referencing outdated material.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

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.