Information Collection

Web-based Customer Service Intake Form

IC 198333 under ICR 201106-1210-001 · OMB 1210-0146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0146 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 301 Web-based Customer Service Intake Form	Form and Instruction
301 Request for Assistance From Department of Labor, EBSA PROPOSED WEB INTAKE FORM clearance 6 29 11.pdf	Form and Instruction

IC Title:

Web-based Customer Service Intake Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	301	Request for Assistance From Department of Labor, EBSA	PROPOSED WEB INTAKE FORM clearance 6 29 11.pdf		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: Technical Assistance and Inquiry Files, DOL/PWBAÂ4

FR Citation: 67 FR 16816

Number of Respondents: 30,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 85 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	15,000	15,000
Annual IC Cost Burden (Dollars)	3,100	3,100

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.