Job Corps Health Questionnaire

Forms and Documents

Document Name	Status
Form ETA 653 Job Corps Health Questionnaire Form and Instruction	Modified
Supporting Statement-1205-0033 final January 23 2014.doc Supporting Statement A	2014-01-23
HIPPA NOTICE.pdf Supplementary Document	2010-11-18
Student Rights to Privacy and Disclosure of Information.pdf Supplementary Document	2010-11-17
Job Corps Privacy Act Statement final approved by OMB 2010.doc Supplementary Document	2010-11-17

IC Document Collections

IC ID	Document Title	Status
12954	Job Corps Health Questionnaire Form and Instruction	Modified

ICR Details

OMB Control No: 1205-0033	ICR Reference No: 201306-1205-001
Status: Historical Active	Previous ICR Reference No: 201010-1205-010
Agency/Subagency: DOL/ETA	Agency Tracking No:
Title: Job Corps Health Questionnaire
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/25/2014
	Date Received in OIRA: 01/28/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2017	36 Months From Approved	03/31/2014
Responses	87,581	0	92,591
Time Burden (Hours)	7,298	0	7,716
Cost Burden (Dollars)	0	0	0

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Abstract: Information on the health status of an applicant to Job Corps is obtained when the applicant completes ETA 653 during an interview with the admissions counselor as part of the admissions process.

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Authorizing Statute(s): PL: Pub.L. 105 - 220 Title 1C Name of Law: The Workforce Investment Act of 1998
  

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:
	78 FR 42803	07/17/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 4494	01/28/2014
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Job Corps Health Questionnaire	ETA 653	Health Questionnaire

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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	87,581	92,591	0	0	-5,010	0
Annual Time Burden (Hours)	7,298	7,716	0	0	-418	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: Fewer applicants filled out the questionnaire over the last three years since the previous extension request in 2010.

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Annual Cost to Federal Government: $198,733

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: 01/28/2014

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