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Information Collection; Health Screening Questionnaire

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Notice; request for comment.


In accordance with the Paperwork Reduction Act of 1995, the Forest Service is seeking comments from all interested individuals and organizations on the extension of a currently approved information collection, Health Screening Questionnaire.


Comments must be received in writing on or before September 4, 2012 to be assured of consideration. Comments received after that date will be considered to the extent practicable.


Comments concerning this notice should be addressed to Washington Office—Fire and Aviation Management, National Interagency Fire Center, 3833 S. Development Ave., Boise, ID 83705, Attention: Larry Sutton.

Comments also may be submitted via facsimile to 208-387-5735 or by email to:

The public may inspect comments received at the National Safety Office, National Interagency Fire Center, Forest Service, USDA, 3833 Development Avenue, Boise, ID, from 8 a.m. to 4:30 p.m. Monday through Friday (Mountain Standard Time). Visitors are encouraged to call ahead to 208-387-5970 to facilitate entry to the building.


Larry Sutton, Forest Service Fire Operations Risk Management Specialist, 208-387-5970. Individuals who use telecommunication devices for the deaf (TDD) may call the Federal Relay Service (FRS) at 1-800-877-8339, twenty-four hours a day, every day of the year, including holidays.


Title: Health Screening Questionnaire.

OMB Number: 0596-0164.

Expiration Date of Approval: January 31, 2013.

Type of Request: Extension with revision of an approved information collection.

Abstract: The Protection Act of 1922 (16 U.S.C. 594) authorizes the Forest Service to fight fires on National Forest System lands. This information collection is an approved Forest Service collection. The collection covers the USDA Forest Service (FS) and the Department of the Interior (DOI), and contains the information collection activities and burden hours for both agencies.

Wildland firefighters perform long hours of arduous labor in adverse environmental conditions. It is imperative that these firefighters be in sufficient physical condition to avoid injury to themselves or their coworkers. Federal employees and private individuals seeking employment as a firefighter with the FS or DOI complete the Health Screening Questionnaire (HSQ). This information collection covers the forms and burden hours associated with the private individuals who apply for firefighter positions with the aforementioned agencies.

Prospective firefighters must complete form FS-5100-31, Health Screening Questionnaire, when seeking employment as a new firefighter with the Forest Service or Department of the Interior. This form collects the following information:

  • Name and Unit.
  • Medical history.
  • Current medical symptoms.
  • Other health issues.
  • Cardiovascular risk factors.

The information collected pertains to an individual's health status and health history in an effort to determine if any physical conditions exist that might result in injury or death during fitness testing or when fighting a wildfire. If Federal agency officials determine, based on the collected information, that an individual may not be physically able to train for or take a Work Capacity Test, the agency will require the individual to undergo a physical examination by a physician.

Form FS-5100-30, Work Capacity Test: Informed Consent, is signed by those deemed to be in sufficient health to undergo a Work Capacity Test. The Work Capacity Test determines the level of an individual's aerobic fitness, level of muscular strength, and muscle endurance. The consent form is necessary to ensure the individual taking the test is aware of the various testing levels (arduous, moderate, and light) and the risks involved. The individual indicates the following:

  • They have read the information on the form, the brochure “Work Capacity Test” and understand the purpose, instructions, and risks of the test.
  • They have read the information, understood, and truthfully answered the HSQ.
  • Test to be taken—pack test (arduous), field test (moderate), or walk test (light).

Failure to collect this data could result in injuries or deaths during the “Work Capacity Test” and while working on wildland fires. The information provided by an applicant for Federal employment is stored in secured official files, maintained according to Agency regulations. The information gathered is not available from other sources.

Estimate of Annual Burden: 5 Minutes.

Type of Respondents: Individuals.

Estimated Annual Number of Respondents: 7,471.

Estimated Annual Number of Responses per Respondents: 1.

Estimated Total Annual Burden on Respondents: 1,240.

Comment Is Invited

Comment is invited on: (1) Whether this collection of information is necessary for the stated purposes and the proper performance of the functions of the Agency, including whether the information will have practical or scientific utility; (2) the accuracy of the Agency's estimate of the burden of the collection of information, including the validity of the methodology and assumptions used; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) ways to minimize the burden of the collection of information on respondents, including the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology.

All comments received in response to this notice, including names and addresses when provided, will be a matter of public record. Comments will be summarized and included in the submission request toward Office of Management and Budget approval.

Dated: June 26, 2012.

Robin L. Thompson,

Associate Deputy Chief, State & Private Forestry.

[FR Doc. 2012-16505 Filed 7-5-12; 8:45 am]