Job Corps Health Questionnaire

Forms and Documents

Document Name	Status
Form ETA-653 Job Corps Health Questionnaire Form and Instruction	Modified
1205-0033 sup statement 6 18 2007.pdf Supporting Statement A	2007-06-18

IC Document Collections

IC ID	Document Title	Status
12954	Job Corps Health Questionnaire Form and Instruction	Modified

ICR Details

OMB Control No: 1205-0033	ICR Reference No: 200706-1205-011
Status: Historical Active	Previous ICR Reference No: 200405-1205-001
Agency/Subagency: DOL/ETA	Agency Tracking No:
Title: Job Corps Health Questionnaire
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: 10/02/2007
	Date Received in OIRA: 06/28/2007
Terms of Clearance: Approved with change. ETA will immediately stop the collection of social security numbers using this tool and replace them with a unique participant identifier already assigned at enrollment. The program does not need to collect SSNs more than once per participant.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2010	36 Months From Approved	09/30/2007
Responses	87,943	0	102,833
Time Burden (Hours)	7,329	0	8,569
Cost Burden (Dollars)	0	0	0

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Abstract: Information on the previous and present health status of applicant must be obtained in an interview by admissions counselor as part of the admissions process.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 15910	04/03/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 35514	06/28/2007
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Job Corps Health Questionnaire	ETA-653	Job Corps Health Questionnaire

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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	87,943	102,833	0	0	-14,890	0
Annual Time Burden (Hours)	7,329	8,569	0	0	-1,240	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a downward adjustment in burden. It is due not to a program change but to a decrease in the number of respondents from 102,833 to 87,943, resulting in a decrease in hour burden from 8,569 to 7,329. The amount of time to complete the form, despite changes to some questions, remains the same: five minutes.

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Annual Cost to Federal Government: $164,083

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

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Common Form ICR:  No

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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: 06/28/2007

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