Health Screening Questionaire

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
3272	Health Screening Questionaire Form	Migrated

ICR Details

OMB Control No: 0596-0164	ICR Reference No: 200408-0596-001
Status: Historical Inactive	Previous ICR Reference No: 200107-0596-001
Agency/Subagency: USDA/FS	Agency Tracking No:
Title: Health Screening Questionaire
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted	Conclusion Date: 10/04/2004
	Date Received in OIRA: 08/30/2004
Terms of Clearance: This collection is improperly submitted because the Forest Service has not adequately described its efforts to consult with persons outside of the agency to obtain their views on the availability of data, frequency of collection, and the clarity of instructions and recordkeeping, disclosure, or reporting format. The agency is reminded that consultation with representatives of those from whom information is to obtained should occur at least once every 3 years--even if the collection of information is the same as in prior periods, barring cicumstances that preclude such consultations. In its revised supporting statement, the agency should address this concern as well as clarify whether the individuals filling out the forms are federal employees at the time, as well as the reason that the number of respondents and responses increased ten fold as compared to the agency's previous submission.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date			10/31/2004
Responses	0	0	1,500
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Medical history, which is provided by completing the HSG, supplies information needed to determine certification of suitability, any special medical or medication needs, and a file record to protect both the Federal Government and individuals.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Health Screening Questionaire	FS-5100-31, FS-5100-30

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/30/2004

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