View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-0787	ICR Reference No: 201401-0938-002
Status: Historical Active	Previous ICR Reference No: 201308-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: 21281
Title: Request for Employment Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/12/2014
	Date Received in OIRA: 01/06/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved	09/30/2016
Responses	15,000	0	15,000
Time Burden (Hours)	5,000	0	3,750
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	15,000	15,000	0
Annual Time Burden (Hours)	5,000	3,750	1,250
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: There is a change in the burden to the time the applicant spends filling out a small section of the form prior to sending the form to the employer for completion. The revised form requires the applicant to fill out Section A. While this activity may have occurred with the previous form, it was not captured in previous burden estimates. We estimate it will take the applicant 5 minutes to fill out Section A of the form. The change in the burden is due to adjustments in the form and operational processes.

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