Information Collection

Application for Mediation Services

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MediationROCISForms.pdf MediationROCISForms	IC Document

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
MediationROCISForms		06/20/2017

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

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