Request for Assistance from the Department of Labor, Employee Benefits Security Administration

Forms and Documents

Document Name	Status
Form 301 Customer Service Intake Form Form and Instruction	Modified
Supporting Statement Web Intake Form 2014.doc Supporting Statement A	2014-09-16

IC Document Collections

IC ID	Document Title	Status
198333	Customer Service Intake Form Form and Instruction	Modified

ICR Details

OMB Control No: 1210-0146	ICR Reference No: 201407-1210-002
Status: Historical Active	Previous ICR Reference No: 201106-1210-001
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Request for Assistance from the Department of Labor, Employee Benefits Security Administration
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: 10/30/2014
	Date Received in OIRA: 09/24/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2017	36 Months From Approved	10/31/2014
Responses	6,500	0	30,000
Time Burden (Hours)	3,250	0	15,000
Cost Burden (Dollars)	0	0	3,100

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Abstract: EBSA assists participants in understanding their rights, responsibilities, and benefits under employee benefit law and intervenes informally on their behalf with the plan sponsor in order to assist them in obtaining the health and retirement benefits to which they may have been inappropriately denied, which can avert the necessity for a formal investigation or a civil action. EBSA has made a request for assistance form available on its Web site for those wishing to obtain assistance in this manner.

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Authorizing Statute(s): None

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:
	79 FR 29208	05/21/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 57133	09/24/2014
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
Customer Service Intake Form	301, 301, 301, 301	Request for Assistance from Department of Labor, EBSA (English Paper Version) ,   Request for Assistance from Department of Labor, EBSA (Spanish Paper Version) ,   Request for Assistance from Department of Labor, EBSA (English Web Option Screenshots) ,   Request for Assistance from Department of Labor, EBSA (Spanish Web Option Screenshots)

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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	6,500	30,000	0	0	-23,500	0
Annual Time Burden (Hours)	3,250	15,000	0	0	-11,750	0
Annual Cost Burden (Dollars)	0	3,100	0	0	-3,100	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: The burden estimates are lower than during the last submission. In the case of the hour burden, the Department made projections on the use of the new form that turned out to be too high. Actual usage was lower than projected, and has been adjusted accordingly for this submission. Further, the Department expected to receive 15 percent of its inquiries through the mail and calculated the cost burden accordingly. In actuality, none of its inquiries were received through the mail, and the Department sees no reason why this will change in the future. The cost to the government has decreased because the costs included in the last submission reflected one-time start-up costs that are no longer applicable for this renewal.

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Annual Cost to Federal Government: $0

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: 09/24/2014

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