Survey of Benefit Determination Letter and Statement

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1212-0066 can be found here:

Documents and Forms

Document Name Document Type
Email to Participants for LR Nelson Plan Final.docx Instruction
Questionnaire for LR Nelson Participants Final.docx Other-Survey
Template for Generic Clearance Submission for Survey 2017 Final.docx Template for Generic Clearance Submission for Survey IC Document

Information Collection (IC) Details

IC Title:	Survey of Benefit Determination Letter and Statement	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Email to Participants for LR Nelson Plan Final.docx		Yes	No	Printable Only
Other-Survey			Questionnaire for LR Nelson Participants Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 39	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	39	39
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Template for Generic Clearance Submission for Survey	Template for Generic Clearance Submission for Survey 2017 Final.docx	10/19/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.