Certification of Identity and Consent Form

Forms and Documents

Document Name	Status
Form 10-945 Certification of Identity and Consent Form and Instruction	New
1024-New Case Incident Report Published Notice 10262016 81207 74478 2016-25847.pdf Supplementary Document	2016-10-26
1024-New PA Case Incident Report Request SSA 10202016.docx Supporting Statement A	2016-10-20
1024-New PA Case Incident Report Form 60-day Published 01152016 81010 2233 2016-00714.pdf Supplementary Document	2016-10-20
NPS Organic Act of 1916 Organic Act 54 USC.pdf Supplementary Document	2016-10-20
Privacy Act of 1974 5 USC §552a.pdf Supplementary Document	2016-10-20
Freedom of Information Act 5 USC §552.pdf Supplementary Document	2016-10-20

IC Document Collections

IC ID	Document Title	Status
224051	Certification of Identity and Consent Form and Instruction	New

ICR Details

OMB Control No: 1024-0280	ICR Reference No: 201610-1024-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOI/NPS	Agency Tracking No:
Title: Certification of Identity and Consent Form
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: 01/17/2017
	Date Received in OIRA: 10/26/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved
Responses	2,000	0	0
Time Burden (Hours)	100	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of the collection is to enable the NPS to locate applicable records and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Information includes sufficient personally identifiable information and/or source documents as applicable. The detailed personal information, to include the date/place of birth, as well as the requestor’s Social Security Number, is needed to identify records unique to the requestor. Failure to provide the required information may result in the NPS being unable to take any action on the request.

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Authorizing Statute(s): US Code: 5 USC 552a Name of Law: Privacy Act
   US Code: 54 USC 100101 Name of Law: National Park Service Organic Act
   US Code: 5 USC 552 Name of Law: Freedom of Information Act
  

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 2233	01/15/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 74478	10/26/2016
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
Certification of Identity and Consent	10-945	Certification of Identity and Consent

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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	2,000	0	0	2,000	0	0
Annual Time Burden (Hours)	100	0	0	100	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: This is an existing collection in use without OMB approval.

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Annual Cost to Federal Government: $6,158

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: 10/26/2016

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