Information Collection

Conflict of Interest and Disclosure Form

IC 46139 under ICR 201005-1218-002 · OMB 1218-0255.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1218-0255 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Conflict of Interest and Disclosure Form	Form and Instruction
Conflict of Interest and Disclosure Form COI_Form_Final_(05-14-10).pdf	Form and Instruction

IC Title:

Conflict of Interest and Disclosure Form

Agency IC Tracking Number:

1218-0255(2010)

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Conflict of Interest and Disclosure Form	COI_Form_Final_(05-14-10).pdf		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 36

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	27	27
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.