Notice of Beneficiary Rights and Beneficiary Referral Request

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
1601-NEW_Supporting Statement - CRCL Faith based Orgs.docx	Supporting Statement A	Uploaded 2016-03-01	Repair queued
EO 13559.pdf	Supplementary Document	Uploaded 2015-05-18	Repair queued
EO 13279.pdf	Supplementary Document	Uploaded 2015-05-18	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
216615	NOTICE OF BENEFICIARY RIGHTS AND BENEFICIARY REFERRAL REQUEST		New

ICR Details

OMB Control No:	ICR Reference No: 201505-1601-001
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: DHS/OS	Agency Tracking No:
Title: Notice of Beneficiary Rights and Beneficiary Referral Request
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 03/09/2016
	Date Received in OIRA: 03/02/2016
Terms of Clearance: The agency will resubmit this collection for an emergency review.

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

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Abstract: Executive Order 13279, as amended by Executive Order 13559, and the Department of Homeland Security's (DHS) proposed regulation implementing those Executive Orders, require that beneficiaries of social service programs provided by faith-based organizations via DHS grant or contract receive certain protections. The beneficiaries must receive notice of those protections, and if they object to the religious character of the providing organization, the organization (and, in some cases, DHS) must undertake efforts to refer the beneficiary to an alternative provider. Making this referral requires collection of basic contact information from the beneficiary as well as a limited amount of additional information regarding the objection to the initial service provider. While the organizations would be required to collect the relevant information from beneficiaries who object and seek a referral, the form itself would be optional; the information could be collected by other means if the organization so chooses.

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Authorizing Statute(s): EO: EO 13279 Name/Subject of EO: Equal Protection of the Laws for Faith-Based and Community Organizations
   EO: EO 13559 Name/Subject of EO: Fundamental Principles and Policymaking Criteria for Partnerships with FaithBased/OtherNeighbor. Org
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1601-AA40	Proposed rulemaking	80 FR 47284	08/06/2015

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
NOTICE OF BENEFICIARY RIGHTS AND BENEFICIARY REFERRAL REQUEST

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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: This is a new collection.

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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: 03/02/2016

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