Pilot Intake Form

Forms and Documents

Document	Type	Status	Availability
CFPB - Consumer Response - Pilot Emergency Justification and Supporting Statement - Final.docx	Supporting Statement A	Uploaded 2011-06-10	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
198060	Paper and Telephone Intake Form	Other-Paper Intake	New
198053	Web Intake Form	Other-Screen Shot	New

ICR Details

OMB Control No: 1505-0236	ICR Reference No: 201106-1505-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: TREAS/DO	Agency Tracking No:
Title: Pilot Intake Form
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: 06/10/2011
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/10/2011
	Date Received in OIRA: 06/10/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2011	6 Months From Approved
Responses	75,000	0	0
Time Burden (Hours)	9,688	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Pilot Intake Form was designed to aid consumers in the submission of a complaint, question, or comment relating to credit cards. The pilot implementation will inform future improvements to the permanent version of the Consumer Response Intake Form and technical assistance.

Emergency Justfication: The Department of the Treasury (“Treasury”), on behalf of itself and the Consumer Financial Protection Bureau (“CFPB”), respectfully requests emergency processing and approval of the collection of information discussed below because normal clearance procedures are reasonably likely to prevent or disrupt the collection of information. Emergency clearance of an information collection request is needed for piloting the Credit Card Specific Consumer Response Intake Form (“Pilot Intake Form”), a web-based, consumer intake data collection form, which will inform the development and implementation of the permanent consumer contact intake form (“Consumer Response Intake Form”). The pilot is scheduled to begin on June 21, 2011. The CFPB initiated a timely review of a comprehensive intake form for the permanent data collection system under normal clearance procedures pursuant to 5 C.F.R. 1320, with an initial 60-day comment period beginning on March 9, 2011. See 76 Fed. Reg. 13018 (March 9, 2011). However, with the formal comment period for the permanent system collection request likely expiring in early July 2011, the CFPB will not have the benefit of the Office of Management and Budget approval by the anticipated pilot launch date. As with any exploratory program, an adequate timeframe must be provided to test the Pilot Intake Form and related processes and obtain the results which may inform the development of the permanent system. The CFPB’s designated transfer date is July 21, 2011, at which time certain consumer financial protection functions of seven federal agencies will transfer to the CFPB. An inadequate timeframe for testing the Pilot Intake Form may preclude the meaningful assessment needed to ensure the timely implementation of the consumer response intake infrastructure contemplated by Title X of the Dodd-Frank Wall Street Reform and Consumer Protection Act, Pub. L. 111-2013, 124 Stat. 1376 (“Dodd-Frank”). See Dodd-Frank §§1013(b)(3)(A), 1021(c)(2), and 1034.

---

Authorizing Statute(s): PL: Pub.L. 111 - 203 1013(b)(3) Name of Law: Dodd–Frank Wall Street Reform and Consumer Protection Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 203 1013(b)(3) Name of Law: Dodd–Frank Wall Street Reform and Consumer Protection Act

---

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: 2

IC Title	Form No.	Form Name
Web Intake Form
Paper and Telephone Intake Form

---

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	75,000	0	75,000	0	0	0
Annual Time Burden (Hours)	9,688	0	9,688	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

---

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]? Yes

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: 06/10/2011

---