Information Collection

Application for Mediation Services

IC 32919 under ICR 201706-3140-003 · OMB 3140-0002.

Documents and Forms

Document Name Document Type
MediationROCISForms.pdf MediationROCISForms IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Mediation Services	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1203.1 29 CFR 1208.5

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
MediationROCISForms	MediationROCISForms.pdf	06/20/2017

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