Third Party Authorization, Privacy Release, Request for Assistance

Ombudsman Request for Assistance

Documents and Forms

Document Name Document Type
Form OPM 1743 Third Party Authorization, Privacy Release, Request for Assistance Form and Instruction
OPM 1743 Ombudsman - Third Party Authorization Third Party Rep final draft June 15 2010.doc Form and Instruction
OPM 1744 Ombudsman Privacy Release Privacy Release final draft June 15 2010.doc Form and Instruction
OPM 1747 Ombudsman Request for Assistance Ombudsman request for assistance.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Third Party Authorization, Privacy Release, Request for Assistance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OPM 1743	Ombudsman - Third Party Authorization	Third Party Rep final draft June 15 2010.doc	No		Paper Only
Form and Instruction	OPM 1744	Ombudsman Privacy Release	Privacy Release final draft June 15 2010.doc	No		Paper Only
Form and Instruction	OPM 1747	Ombudsman Request for Assistance	Ombudsman request for assistance.pdf	Yes	Yes	Fillable Fileable

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	2,000	2,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.