Ombudsman Request for Assistance

Forms and Documents

Document Name	Status
Form OPM 1743 Third Party Authorization, Privacy Release, Request for Assistance Form and Instruction	New
Supporting Statement_ombudsman 7 18 2011.docx Supporting Statement A	2011-08-01
Ombudsman Charter 1 .pdf Supplementary Document	2011-06-28
published 30 day notice.pdf Supplementary Document	2011-05-26
published 60 day.pdf Supplementary Document	2011-05-26

IC Document Collections

IC ID	Document Title	Status
198318	Third Party Authorization, Privacy Release, Request for Assistance Form and Instruction	New

ICR Details

OMB Control No: 3206-0256	ICR Reference No: 201010-3206-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: OPM	Agency Tracking No:
Title: Ombudsman Request for Assistance
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: 09/30/2011
	Date Received in OIRA: 08/01/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	36 Months From Approved
Responses	4,000	0	0
Time Burden (Hours)	2,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: OPM established the Ombudsman to provide a neutral, independent and confidential resource to review, identify, facilitate and timely resolve individual claims, concerns or complaints by OPM customers and employees. The Ombudsman office also provides an independent source of information to assist in identifying persistent, continuing or systemic concerns and issues that may merit attention, prevention, and resolution; assist in coordinating processes by which questions or concerns are addressed; provide anonymity to any party wishing to raise a workplace issue; facilitate recognition, prevention and resolution of workplace disputes without resorting to formal means of dispute resolution; and facilitate review of OPM processes or procedures which may impact OPMs mission, workplace, or employee morale. The Ombudsman works by promoting and encouraging high-quality customer service and seeking continuous improvement by inviting customer involvement. In order to provide the best service to OPM customers one form is required and two forms are optional. The mandatory form, Privacy Release, enables representatives of the Ombudsman's office to obtain any information requested, examine and/or copy any records related to a request for assistance to identify, facilitate and timely resolve individual claims, concerns or complaints by OPM customers and employees. The allows OPM's representatives to properly perform their roles and not violate customer's privacy without the proper authorization. The second form, Third Party Authorization, allows customers of the Ombudsman's office to designate someone in addition to themselves, or other than themselves, to give and receive information about their request for assistance. The Third Party Authorization will not be used in every request for assistance. The third form, Request for Assistance, is a web-enabled one and provides customers a useful tool for their use to provide OPM information it needs to expediently gather the facts and resolve the concern brought before the Ombudsman. The Request for Assistance was developed with drop-down menus for ease of use and to collect the most important information OPM needs to bring resolution.

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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:
	75 FR 48383	08/10/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 79050	12/17/2010
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
Third Party Authorization, Privacy Release, Request for Assistance	OPM 1747, OPM 1744, OPM 1743	Ombudsman - Third Party Authorization ,   Ombudsman Privacy Release ,   Ombudsman Request for Assistance

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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	4,000	0	0	4,000	0	0
Annual Time Burden (Hours)	2,000	0	0	2,000	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: The Ombudsman is a new program within the Office of Personnel Management.

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Annual Cost to Federal Government:

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 08/01/2011

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