Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical

Applications for Merchant Mariner Credentials and Medical Certificates

Documents and Forms

Document Name Document Type
1625-0040_Inst_r1_2023-mmc_pmc-fr.docx Instruction
CG-719B Application for Merchant Mariner Credential Application for Merchant Mariner Credential (Form CG-719B).pdf Form and Instruction
CG-719C Disclosure Statement for Narcotics, DWI/DUI, and/or Othe Disclosure Statement for Narcotics, DWI_DUI, and_or Other Convictions (Optional Form CG-719C).pdf Form and Instruction
CG-719K Application for Medical Certificate Application for Medical Certificate (Form CG-719K).pdf Form and Instruction
CG-719K/E Application for Medical Certificate, Short Form Application for Medical Certificate, Short Form (Form CG-719K_E.pdf Form and Instruction
CG-719P DOT/USCG Periodic Drug Testing Form CG719P.pdf Form
CG-719S Small Vessel Sea Service Form CG719S.pdf Form

Information Collection (IC) Details

IC Title:	Continuous Discharge Book, Application, Physical Exam Report, Sea Service Report, Chemical Testing, Entry Lvl Physical	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 46 CFR 11 46 CFR 12 46 CFR 16 46 CFR 10

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			1625-0040_Inst_r1_2023-mmc_pmc-fr.docx	Yes	Yes	Printable Only
Form and Instruction	CG-719B	Application for Merchant Mariner Credential	Application for Merchant Mariner Credential (Form CG-719B).pdf	Yes	Yes	Fillable Printable
Form and Instruction	CG-719C	Disclosure Statement for Narcotics, DWI/DUI, and/or Other Convictions	Disclosure Statement for Narcotics, DWI_DUI, and_or Other Convictions (Optional Form CG-719C).pdf	Yes	Yes	Fillable Printable
Form and Instruction	CG-719K	Application for Medical Certificate	Application for Medical Certificate (Form CG-719K).pdf	Yes	Yes	Fillable Printable
Form and Instruction	CG-719K/E	Application for Medical Certificate, Short Form	Application for Medical Certificate, Short Form (Form CG-719K_E.pdf	Yes	Yes	Fillable Printable
Form	CG-719P	DOT/USCG Periodic Drug Testing Form	CG719P.pdf	Yes	Yes	Fillable Printable
Form	CG-719S	Small Vessel Sea Service Form	CG719S.pdf	Yes	Yes	Fillable Printable

Line of Business: Transportation

Subfunction: Water Transportation

Privacy Act System of Records
Title: Merchant Seamen's Records	FR Citation: 74 FR 30308

Number of Respondents: 90,293	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 90 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	310,091	-513	310,604
Annual IC Time Burden (Hours)	61,850	-154	62,004
Annual IC Cost Burden (Dollars)	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.