Employment Reference Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OMB Number 1103-NE Employee Reference Questionnaire	Form	New	Repair queued
83i-DOJ-Employment-Reference-Form_112812.pdf	Supplementary Document	Uploaded 2012-11-28	Repair queued
Authorizing Statute_CFR-2012-title5-vol1-sec5-2.pdf	Supplementary Document	Uploaded 2012-11-28	Repair queued
1103-NEW_DOJ Empl Ref Questionnaire Supporting Statement_112812.docx	Supporting Statement A	Uploaded 2012-11-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
204963	Employee Reference Questionnaire	Form	New

ICR Details

OMB Control No:	ICR Reference No: 201211-1103-001
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: DOJ/DOJADM	Agency Tracking No:
Title: Employment Reference Questionnaire
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 03/21/2013
	Date Received in OIRA: 11/28/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The form collects pre-employment reference and suitability information on candidates for employment with the Department of Justice. The Department has initiated this as part of its SAVE Program. Use of the form produces savings by eliminating unsuitable candidates without the full cost of a formal background investigation. Hiring or selecting officials use the form to ensure consistent, comprehensive collection of employment references. Respondents are prior supervisors of the candidate.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 25749	05/01/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 47437	08/08/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Employee Reference Questionnaire	OMB Number 1103-NEW	Employee Reference Questionnaire

---

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: 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]? 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

---

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: 11/28/2012

---