Non-Insulin-Treated Diabetes Mellitus Assessment Form

ICR 202306-2126-003

OMB: 2126-0081

Federal Form Document

IC Document Collections
ICR Details
202306-2126-003
Received in OIRA
DOT/FMCSA
Non-Insulin-Treated Diabetes Mellitus Assessment Form
New collection (Request for a new OMB Control Number)   No
Regular 08/28/2023
  Requested Previously Approved
36 Months From Approved
242,057 0
32,274 0
0 0

FMCSA seeks the Office of Management and Budget’s (OMB) approval of a new ICR titled, Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872. This ICR is voluntary and may be utilized by medical examiners (ME), who issue Medical Examiner’s Certificates, Form MCSA-5876, to individuals who operate commercial motor vehicles (CMV) in interstate commerce, to communicate with treating healthcare providers responsible for managing the individuals’ diagnosed non-insulin-treated diabetes mellitus. The purpose of the Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872, is to assist the ME in determining whether an individual diagnosed with non-insulin-treated diabetes mellitus is physically qualified and the individual’s physical condition is adequate to enable the individual to operate a CMV safely. Because this collection is voluntary, there is no set schedule for CMV operators or MEs to complete the form MCSA-5872. FMCSA estimates that MEs will request that forms be completed for 242,057 individuals with a corresponding number of treating healthcare providers.

US Code: 49 USC §§ 31502(b) Name of Law: Motor Carrier Safety
   US Code: 49 USC §§ 31136 Name of Law: Commercial Motor Vehicle Safety
  
None

Not associated with rulemaking

  88 FR 22517 04/13/2023
88 FR 58061 08/24/2023
Yes

1
IC Title Form No. Form Name
Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872 MCSA-5872 Non-Insulin-Treated Diabetes Mellitus Assessment Form

  Total Request 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 242,057 0 0 0 242,057 0
Annual Time Burden (Hours) 32,274 0 0 0 32,274 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
This is a new ICR therefore there is a burden increase.

$0
No
    Yes
    Yes
No
No
No
No
Christine Hydock 202 366-1220 christine.hydock@dot.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.
08/28/2023


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