Self Certification Medical Statement

Self-Certification Medical Statement

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0579-0196 can be found here:

Documents and Forms

Document Name Document Type
Form MRP Form 5-R Self Certification Medical Statement Form
MRP Form 5-R Self-Certification Medical Statement MRP 5-R OCT 2017.pdf www.aphis.usda.gov/library/forms/pdf/mrp5_r.pdf Form

Information Collection (IC) Details

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

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	MRP Form 5-R	Self-Certification Medical Statement	MRP 5-R OCT 2017.pdf	https://www.aphis.usda.gov/library/forms/pdf/mrp5_r.pdf	Yes	No	Fillable Printable

Line of Business: Natural Resources

Subfunction: Agricultural Innovation and Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 606	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	607	1	284	322
Annual IC Time Burden (Hours)	102	1	47	54
Annual IC Cost Burden (Dollars)	0	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.