View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 3206-0162	ICR Reference No: 201703-3206-003
Status: Historical Active	Previous ICR Reference No: 201402-3206-006
Agency/Subagency: OPM	Agency Tracking No:
Title: OPM 1530, Report of Medical Examination of Person Electing Survivor Benefits Under the Civil Service Retirement System
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/02/2017
	Date Received in OIRA: 05/15/2017
Terms of Clearance: OPM should review the privacy act statement on the form before it it next submitted for OMB review. In addition, please provide the most recent PIA and SORN with the renewal materials. This collection should be reported in the information collection budget.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	6 Months From Approved
Responses	500	0	0
Time Burden (Hours)	750	0	0
Cost Burden (Dollars)	0	0	0

Annual Cost to Federal Government: $24,150

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Charles Conyers 202 606-0125 charles.conyers@opm.gov

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