OSHA's Conflict of Interest and Disclosure Form

Forms and Documents

Document Name	Status
Conflict of Interest and Disclosure Form Form and Instruction	New
SS-Confict of Interest Form toOMB rev 032307_redline.doc Supplementary Document	2007-04-02
COI form APPENDIX A rev 032307_redline.doc Supplementary Document	2007-04-02
COI Long Form rev 032307.doc Supplementary Document	2007-04-02
COI Short Form rev 032307.doc Supplementary Document	2007-04-02
OSHA RESPONSE TO AMERICAN CHEMISTRY COUNCIL CRYSTALLINE SILICA PANEL COMMENT TO OMB ON OSHA CONFLICT OF INTEREST AND DISCLOSURE FORM.doc Supplementary Document	2007-04-02
COI Form Final 12~19~06[1].doc Supplementary Document	2006-12-21
SS-Confict of Interest Form 12~19~06.doc Supporting Statement A	2006-12-21
60-dayf.pdf Supplementary Document	2006-11-24
OMB_peer_bulletin_final.pdf Supplementary Document	2006-11-24

IC Document Collections

IC ID	Document Title	Status
46139	Conflict of Interest and Disclosure Form Form and Instruction	New

ICR Details

OMB Control No: 1218-0255	ICR Reference No: 200611-1218-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOL/OSHA	Agency Tracking No: 1218-0New(2006)
Title: OSHA's Conflict of Interest and Disclosure Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/03/2007
	Date Received in OIRA: 12/21/2006
Terms of Clearance: Approved consistent with Agency revisions outlined in attached supplemental documents.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2010	36 Months From Approved
Responses	36	0	0
Time Burden (Hours)	27	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Conflict of Interest and Disclosure form will be used to determine whether or not a conflict of interest exists for a potential peer review panel member.

---

Authorizing Statute(s): PL: Pub.L. 106 - 554 515(1) Name of Law: Information Quality Act
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 44714	08/07/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 76689	12/21/2006
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Conflict of Interest and Disclosure Form	none	Conflict of Interest and Disclosure form

---

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	36	0	0	36	0	0
Annual Time Burden (Hours)	27	0	0	27	0	0
Annual Cost Burden (Dollars)	0	0	0	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: There is an increase of 27 hours for obtaining the necessary background information and disclosure of conflict of interest information to ensure invited experts not be compromised. There are no costs as discussed under Item 13 of the Supporting Statement.

---

Annual Cost to Federal Government: $936

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

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: 12/21/2006

---