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: 1405-0214	ICR Reference No: 201908-1405-007
Status: Historical Active	Previous ICR Reference No: 201607-1405-005
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Supplemental Questionnaire to Determine Entitlement for a U.S. Passport
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/26/2021
	Date Received in OIRA: 08/29/2019
Terms of Clearance: The agency provided clarifications in the supporting statement and updated instructions and guidance for the form, including on its website. The form is now available on the agency's eForms web page as well.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2024	36 Months From Approved	03/31/2021
Responses	4,076	0	3,257
Time Burden (Hours)	5,774	0	4,614
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	4,076	3,257	819
Annual Time Burden (Hours)	5,774	4,614	1,160
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: The program change reflects an increase in respondents’ use of this form from 3,257 to 4,076. This is likely due to the increase in number of DS-11s over the last three years.

Annual Cost to Federal Government: $49,931

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? No

Agency Contact: Maya Badiat 202 485-6530

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