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: 3206-0179	ICR Reference No: 201802-3206-001
Status: Historical Active	Previous ICR Reference No: 201603-3206-010
Agency/Subagency: OPM	Agency Tracking No: RI 30-10
Title: Disabled Dependent Questionnaire
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 with change	Conclusion Date: 06/04/2018
	Date Received in OIRA: 02/22/2018
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency. OPM must report this collection as part of the information collection budget. In addition, before this collection is next submitted to OMB for approval, OPM should consider if it should be a common form as it appears to be a information collection in use government-wide for the same purpose.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	36 Months From Approved
Responses	2,500	0	0
Time Burden (Hours)	2,500	0	0
Cost Burden (Dollars)	0	0	0

Annual Cost to Federal Government: $7,725

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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