OSC Complainant Forms 11, 12, and 13

Forms and Documents

Document Name	Status
Form OSC Form 12 OSC Complaint Forms 11,12 and 13 Form	New
Supporting Statement A for OSC Forms 11, 12, and 13 (5).doc Supporting Statement A	2015-07-01

IC Document Collections

IC ID	Document Title	Status
214485	OSC Complaint Forms 11,12 and 13 Form	New

ICR Details

OMB Control No: 3255-0004	ICR Reference No: 201501-3255-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: OSC	Agency Tracking No:
Title: OSC Complainant Forms 11, 12, and 13
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: Approved without change	Conclusion Date: 07/01/2015
	Date Received in OIRA: 01/06/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved
Responses	5,076	0	0
Time Burden (Hours)	6,232	0	0
Cost Burden (Dollars)	51	0	0

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Abstract: This is a request for the renewal of the forms for another 3 year period. OSC Form 11 is for Prohibited Personnel Practices complaints, OSC Form 12 is for Whistleblower Disclosure cases, and OSC Form 13 is for Hatch Act violations. These forms exist in both paper and electronic format. In the near future, we plan on combining the three forms electronically, in such a way that the complainant/whistleblower only sees the portion of the form that pertains to them.

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Authorizing Statute(s): US Code: 5 USC CFR 1800 Name of Law: Code of Federal Regulations
  

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 20247	04/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 35579	06/23/2014
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
OSC Complaint Forms 11,12 and 13	OSC Form 13, OSC Form 12, OSC Form 11	Whistleblower Disclosure Form ,   Complaint of Possible Prohibited Personnel Practice ,   Complaint of Possible Prohibited Political Activity (Violation of the Hatch Act)

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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	5,076	0	0	5,076	0	0
Annual Time Burden (Hours)	6,232	0	0	6,232	0	0
Annual Cost Burden (Dollars)	51	0	0	51	0	0

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: In the past, we did not attempt to keep up with the increase of the number of complainants who use our complaint forms. There also was no attempt to capture the cost to our agency in managing the survey. Now that we are using survey monkey, it makes it easier to determine what our costs are.

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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? Yes

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: 01/06/2015

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