View Information Collection Request (ICR) Package
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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:
3045-0196
ICR Reference No:
202111-3045-001
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
CNCS
Agency Tracking No:
Title:
Forms related to Reasonable Accommodation for Personal Health and Religious Information
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Emergency
Approval Requested By:
12/08/2021
OIRA Conclusion Action:
Approved with change
Conclusion Date:
12/03/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/29/2021
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2022
6 Months From Approved
Responses
40
0
0
Time Burden (Hours)
70
0
0
Cost Burden (Dollars)
5,955
0
0
Abstract:
To meet the requirements of the Executive Orders and Task Force recommendations, AmeriCorps is seeking to create and maintain a Reasonable Accommodations system of records to allow for the collection and protection of information related to medical-based accommodation requests and accommodation requests made for sincerely held religious beliefs, practices, or observances. The forms associated with this system of records will facilitate the processing of requests for exemptions from the vaccine requirement.
Emergency Justfication:
See attached memo.
Authorizing Statute(s):
US Code:
42 USC 12501
Name of Law: National Community Service Act et. seq.
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Reasonable Accommodation related to Vaccination Forms
1, 2
COVID 19 Medical Accommodation Request
,
COVID-19 Religious Accommodation Request
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
40
0
0
40
0
0
Annual Time Burden (Hours)
70
0
0
70
0
0
Annual Cost Burden (Dollars)
5,955
0
0
5,955
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 burden has increased because this is a new information collection
Annual Cost to Federal Government:
$4,700
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?
Yes
Agency Contact:
Amy Borgstrom 202 606-6930 aborgstrom@cns.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
11/29/2021
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