Specific Release Form

Forms and Documents

Document Name	Status
Form 1600-XX Specific Release Form Form	New
2120-Specific Release.doc Supporting Statement A	2009-04-23

IC Document Collections

IC ID	Document Title	Status
188937	Specific Release Form Form	New

ICR Details

OMB Control No: 2120-0740	ICR Reference No: 200904-2120-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOT/FAA	Agency Tracking No:
Title: Specific Release 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 without change	Conclusion Date: 09/29/2009
	Date Received in OIRA: 05/30/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2012	36 Months From Approved
Responses	270	0	0
Time Burden (Hours)	23	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Investigations are conducted under authority derived from Title 49, United States Code (U.S.C.), Sections 106, 40113, 40114, 46101, and 46104, the Aviation Drug Trafficking Control Act of 1984, the Anti-Drug Abuse Act of 1986, and the FAA Drug Enforcement Assistance Act of 1988, which is part of Public Law 100-690, also known as the Anti-Drug Abuse Act of 1988. The respondents are the SUBJECT (FAA employees, FAA Contractors, Pilots, or FAA job applicants) from whom additional information is needed to complete a thorough investigation.

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Authorizing Statute(s): US Code: 49 USC 40113 Name of Law: Administrative
   US Code: 49 USC 40114 Name of Law: Reports and records
   US Code: 49 USC 46101 Name of Law: Complaints and investigations
   US Code: 49 USC 46104 Name of Law: Evidence
  

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:
	74 FR 7281	02/13/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 18604	04/23/2009
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Specific Release Form	1600-XX	Specific Release Form

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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	270	0	0	270	0	0
Annual Time Burden (Hours)	23	0	0	23	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: This is a new collection, therefore it is a program change.

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Annual Cost to Federal Government: $2,268

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)? No

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: 05/30/2009

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