Exchange Accidents/Incidents Reports

Forms and Documents

Document Name	Status
Form Exchange Form 3900 Exchange Form 3900-017 "Statement" Form and Instruction	New
SUPPORTING STATEMENT(Accident Incident-20 JUL 16)(2).DOCX Supporting Statement A	2016-08-11
SSN JUSTIFICATION(2).PDF Supplementary Document	2016-08-11
DRAFT - PIA - APIS(2).PDF Supplementary Document	2016-08-11
DRAFT SORN AAFES 0409(2).PDF Supplementary Document	2016-08-11

IC Document Collections

IC ID	Document Title	Status
222957	Exchange Form 3900-017 "Statement" Form and Instruction	New

ICR Details

OMB Control No: 0702-0138	ICR Reference No: 201608-0702-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOD/DOA	Agency Tracking No:
Title: Exchange Accidents/Incidents Reports
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/12/2016
	Date Received in OIRA: 08/11/2016
Terms of Clearance: DOD must report this collection in the Information Collection Budget.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved
Responses	4,854	0	0
Time Burden (Hours)	4,854	0	0
Cost Burden (Dollars)	35,192	0	0

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Abstract: Pursuant with Army Regulation 215-8/AFI 34-211(I) Chapter 13 and to adhere and resolve eligible patron issues and concerns, collection of information is required from the public to record incidents such as accidents, injuries, illnesses, mishaps, fires, theft or any issues involving government property. The recording of this information is necessary as a basis for payment of claims, providing medical treatment to those who are injured or ill, recovering damages on government property or assets, shoplifting and theft, and having supporting evidence in the event of legal actions.

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Authorizing Statute(s): US Code: 10 USC 8013 Name of Law: null
   EO: EO 12196 Name/Subject of EO: null
   US Code: 10 USC 3013 Name of Law: null
  

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 31918	05/20/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 53128	08/11/2016
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
Exchange Form 3900-017 "Statement"	Exchange Form 3900-017	Statement

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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	4,854	0	0	0	0	4,854
Annual Time Burden (Hours)	4,854	0	0	0	0	4,854
Annual Cost Burden (Dollars)	35,192	0	0	0	0	35,192

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: $1,110,164

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: 08/11/2016

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