Peace Corps Reference Forms

Forms and Documents

Document Name	Status
Form PCR Professional R Peace Corps Response Reference Forms Form and Instruction	New
PCR References Supporting Statement v3.docx Supporting Statement A	2011-12-05
CFR-2011-title22-vol2-part305.pdf Supplementary Document	2011-08-09

IC Document Collections

IC ID	Document Title	Status
198820	Peace Corps Response Reference Forms Form and Instruction	New

ICR Details

OMB Control No: 0420-0548	ICR Reference No: 201108-0420-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: PEACE	Agency Tracking No:
Title: Peace Corps Reference Forms
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/27/2011
	Date Received in OIRA: 12/05/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved
Responses	700	0	0
Time Burden (Hours)	117	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected on the Reference Forms for Peace Corps Response Candidates as an integral part of the screening and selection process and is used to determine whether an applicant would be a good candidate as a Peace Corps Response volunteer. The information obtained from these forms is used by the recruitment and placement specialists within the Office of Peace Corps Response.

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Authorizing Statute(s): US Code: 22 USC 2501 Name of Law: Peace Corps Act
  

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:
	76 FR 28246	05/16/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 44050	07/22/2011
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
Peace Corps Response Reference Forms	PCR Professional Reference Form, PC 2105-B	2105-A ,   PCR Personal Reference Form

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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	700	0	0	0	0	700
Annual Time Burden (Hours)	117	0	0	0	0	117
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:

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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: 08/09/2011

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