DISTRIBUTION OF FEHB/FEGLI IMPLEMENTATION QUESTIONNAIRE TO TRIBES AND URBAN INDIAN ORGANIZATIONS

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0 FEHB/ FEGLI Implementation Questionnaire for Tribes and Tribal Organizations	Form and Instruction	New	Available
SUPPORTING STATEMENT-2.doc	Supporting Statement A	Uploaded 2010-10-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
194771	FEHB/ FEGLI Implementation Questionnaire for Tribes and Tribal Organizations	Form and Instruction	New

ICR Details

OMB Control No: 3206-0251	ICR Reference No: 201010-3206-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: OPM	Agency Tracking No:
Title: DISTRIBUTION OF FEHB/FEGLI IMPLEMENTATION QUESTIONNAIRE TO TRIBES AND URBAN INDIAN ORGANIZATIONS
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 10/01/2010
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/03/2010
	Date Received in OIRA: 10/01/2010
Terms of Clearance: This collection is approved to permit the agencies to collect preliminary, anecdotal data. OMB advises that the results of this collection should not be relied upon to develop statistical estimates or to justify significant policy decisions. OMB welcomes the opportunity to work with the agencies to develop future collections that comport with OMB’s Standards and Guidelines for Statistical Surveys to ensure that the agencies obtain reliable statistical information that is representative of the population.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2011	6 Months From Approved
Responses	600	0	0
Time Burden (Hours)	200	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This questionnaire is required to gather information needed to properly scope and implement the provision in S. 1790, the Indian Health Care Improvement Reauthorization and Extension Act of 2009, allowing for eligible Tribes and urban Indian organizations to purchase FEHB and FEGLI coverage. This questionnaire also serves to initiate Tribal consultation in accordance with Executive Order 13175.

Emergency Justfication: OPM requests an emergency review of this FEHB/ FEGLI Implementation Questionnaire for Tribes and Tribal Organizations so critical information regarding the eligible population can be gathered in order to proceed with implementation by January 2011. This is in accordance with the statutorily mandated provision providing eligible tribes with the opportunity to purchase FEHB and FEGLI coverage. In absence of this collection, there is insufficient information available to adequately determine the scope and cost of implementation. This questionnaire serves to gather the requisite information, allowing OPM to proceed with the implementation process. An emergency review of the above mentioned questionnaire will ensure this information can be gathered expeditiously, so this provision can be properly scoped, implemented, and operational as quickly as possible.

---

Authorizing Statute(s): EO: EO 13175 Name/Subject of EO: Consultation and Coordination with Indian Tribal Governments
  

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

Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
FEHB/ FEGLI Implementation Questionnaire for Tribes and Tribal Organizations	0	FEHB/ FEGLI Implementation Questionnaire for Tribes and Tribal Organizations

---

ICR Summary of Burden

table that charts list 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	600	0	0	600	0	0
Annual Time Burden (Hours)	200	0	0	200	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 for OPM in support of E.O. 13175.

---

Annual Cost to Federal Government: $0

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]? Yes

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

---

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: 10/01/2010

---