Occupational Safety and Health Administration Conflict of Interest and Disclosure Form

Forms and Documents

Document Name	Status
Form OSHA Form 10-80.1 OSHA's Conflict of Interest (COI) and Disclosure Form Form	Modified
SS_1218-0255_(12-2-2013).docx Supporting Statement A	2013-12-05
FR (COI) 7-16-13.pdf Supplementary Document	2013-11-20
OMB_peer_bulletin_final.pdf Supplementary Document	2010-05-13

IC Document Collections

IC ID	Document Title	Status
46139	OSHA's Conflict of Interest (COI) and Disclosure Form Form	Modified

ICR Details

OMB Control No: 1218-0255	ICR Reference No: 201311-1218-007
Status: Historical Active	Previous ICR Reference No: 201005-1218-002
Agency/Subagency: DOL/OSHA	Agency Tracking No: 1218-0255(2013)
Title: Occupational Safety and Health Administration Conflict of Interest and Disclosure Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/06/2014
	Date Received in OIRA: 12/27/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved	02/28/2014
Responses	36	0	36
Time Burden (Hours)	27	0	27
Cost Burden (Dollars)	0	0	0

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Abstract: The Conflict of Interest and Disclosure form will be used to determine whether or not a conflict of interest exists for a potential peer review panel member.

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Authorizing Statute(s): PL: Pub.L. 106 - 554 515(1) Name of Law: Information Quality 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:
	78 FR 42549	07/16/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 78388	12/26/2013
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
OSHA's Conflict of Interest (COI) and Disclosure Form	OSHA Form 10-80.1, OSHA Form 10-80.2	COI Short Form ,   COI Long 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	36	36	0	0	0	0
Annual Time Burden (Hours)	27	27	0	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:

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Annual Cost to Federal Government: $936

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: 12/27/2013

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