Contractor Information Worksheet; GSA Form 850

ICR 201611-3090-003

OMB: 3090-0283

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2017-01-09
Supporting Statement A
2016-11-30
IC Document Collections
ICR Details
3090-0283 201611-3090-003
Historical Active 201512-3090-001
GSA
Contractor Information Worksheet; GSA Form 850
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 01/11/2017
Retrieve Notice of Action (NOA) 01/09/2017
  Inventory as of this Action Requested Previously Approved
07/31/2019 07/31/2019 07/31/2019
25,000 0 25,000
6,250 0 6,250
248,625 0 248,625

GSA requires the collection of the information in the Contractor Information Worksheet to authorize and initiate background check requests for GSA contractors and to obtain a GSA Access Card. The background checks are carried out by the Office of Personnel Management, Facilities, Security & Contracting-Personnel Security (OPM FSC) and the credentialing process is carried out by the GSA’s Managed Service Office (MSO) in accordance with the terms and conditions of separate Memoranda of Agreement (MOAs). A non-substantive change regarding the Contractor Information Worksheet is being submitted because the header on number 2 of the worksheet will now require a GSA Requesting Official fill out the portion instead of a Contracting Officer. Also, there were unnecessary spaces on the worksheet that were removed.

None
None

Not associated with rulemaking

  80 FR 75864 12/04/2015
81 FR 20639 04/08/2016
No

1
IC Title Form No. Form Name
Contractor Information Worksheet, GSA Form 850 GSA 850 Contractor Information Worksheet

  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 25,000 25,000 0 0 0 0
Annual Time Burden (Hours) 6,250 6,250 0 0 0 0
Annual Cost Burden (Dollars) 248,625 248,625 0 0 0 0
No
No

$137,480
No
No
No
No
No
Uncollected
Phil Ahn 202 501-2447

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/09/2017


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