0196 2025 Aphis 79

OMB CONTROL NO.	0579-0196				DATE PREPARED	01/14/2025
TITLE OF INFORMATION COLLECTION REQUEST (ICR)	Self-Certification Medical Statement
Additional line for ICR Title if title is too long
	OPM PAY TABLE (A)	09/2019 Benefits account for 38% of employee costs and wages account for the remaining 62%. W = .62 x TC TC = 1.6129 x W FB = .38 x TC TC = 2.6316 x FB 2.6316 x FB = TC = 1.6129 x W FB = (1.6129 / 2.6316) x W FB = .613 x W Fringe Benefits = Wages x .613 FRINGE BENEFITS FACTOR (B)	OVERHEAD COST FACTOR (C)			TOTAL FEDERAL GOVERNMENT COSTS
Activity descriptions and calculations are below.	2025-MSP	0.613	0.139			$2,250
ACTIVITY DESCRIPTION (incl form number)	TOTAL ANNUAL RESPONSES (D)	AVG TIME PER RESPONSES (E)	TOTAL HOURS PER YEAR (F)	GRADE (G)	WAGE (Step 4) (H)	TOTAL COSTS (1+B+C) x F x H
Self-Certification Medical Statement	175	0.167	29	GS 11	$42.49	$2,175.58
Request for Waiver of Standards and Requirements	1	1	1	GS 11	$42.49	$74.44