Report of Public Safety Officers' Death

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 3650/6 Report of Public safety Officer's Death	Form	Modified	Available
1121-0025_REPORT OF DEATH JUSTIFICATION 2006 REVISED.doc	Supporting Statement A	Uploaded 2016-05-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
12366	Report of Public Safety Officers' Death	Form	Modified	Report of Public safety Officer's Death

ICR Details

OMB Control No: 1121-0025	ICR Reference No: 201605-1121-003
Status: Historical Active	Previous ICR Reference No: 200404-1121-003
Agency/Subagency: DOJ/OJP	Agency Tracking No: BJA
Title: Report of Public Safety Officers' Death
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/27/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/17/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2019	36 Months From Approved
Responses	275	0	0
Time Burden (Hours)	550	0	0
Cost Burden (Dollars)	2,578	0	0

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Abstract: This information collection is required to carry out the functions of the PSOB Program. The program provides a one-time benefit of $250,000 to the eligible survivors of local, state, and federal public safety officers whose deaths result from traumatic injuries sustained in the line of duty. The Report of Public Safety Officer's Death form is completed by the employing agency. The form includes information necessary to determine that the circumstances of death meet the requirements prescribed in 42 USC Sec. 3796.

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Authorizing Statute(s): US Code: 42 USC 3796 Name of Law: The Public Safety Officers Benefits
  

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:
	81 FR 1224	01/11/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 19240	04/04/2016
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
Report of Public Safety Officers' Death	3650/6	Report of Public safety Officer's Death

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ICR Summary of Burden

table that charts list 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	275	0	0	-45	0	320
Annual Time Burden (Hours)	550	0	0	-250	0	800
Annual Cost Burden (Dollars)	2,578	0	0	-422	0	3,000

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The number of respondents decreased slightly.

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Annual Cost to Federal Government: $28,275

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: 05/17/2016

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