Report of Public Safety Officers' Permanent and Total Disability

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1121-0166 can be found here:

Documents and Forms

Document Name Document Type
Form OJP form 3650/7 Report of Public Safety Officers' Permanent and Total Disability Form
OJP form 3650/7 Public Safety Officer's Benefits Program PSOB_DISABILITY_FORM.pdf www.ojp.usdoj.gov/BJA/grant/psob/psob_main.html Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Report of Public Safety Officers' Permanent and Total Disability	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	OJP form 3650/7	Public Safety Officer's Benefits Program	PSOB_DISABILITY_FORM.pdf	http://www.ojp.usdoj.gov/BJA/grant/psob/psob_main.html	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	75	30	45
Annual IC Time Burden (Hours)	188	98	90
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.