USM-164 Applicant Appraisal Questionnaire

Forms and Documents

Document	Type	Status	Availability
Form Form USM-164 Form USM-164 - USMS Applicant Appraisal Questionnaire	Form and Instruction	New	Repair queued
USM-164 - Supporting Statement (PRA)_18JUN18.docx	Supporting Statement A	Uploaded 2018-06-25	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
231921	Form USM-164 - USMS Applicant Appraisal Questionnaire	Form and Instruction	New

ICR Details

OMB Control No: 1105-0106	ICR Reference No: 201707-1105-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: DOJ/LA	Agency Tracking No:
Title: USM-164 Applicant Appraisal Questionnaire
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/11/2018
	Date Received in OIRA: 08/07/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2021	36 Months From Approved
Responses	1,500	0	0
Time Burden (Hours)	500	0	0
Cost Burden (Dollars)	20,745	0	0

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Abstract: This form will primarily be used to collect applicant reference information. Reference checking is an objective evaluation of an applicant’s past job performance based on information collected from key individuals (e.g. supervisors, peers, subordinates) who have known and worked with the applicant. Reference checking is a necessary supplement to the evaluation of resumes and other descriptions of training and experience, and allows the selecting official to hire applicants with a strong history of performance. The questions on this form have been developed following the OPM, MSPB, and DOJ “Best Practice” guidelines for reference checking.

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Authorizing Statute(s): None

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:
	82 FR 25816	06/05/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 30976	07/02/2018
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
Form USM-164 - USMS Applicant Appraisal Questionnaire	Form USM-164	USMS Applicant Appraisal Questionnaire

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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	1,500	0	0	1,500	0	0
Annual Time Burden (Hours)	500	0	0	500	0	0
Annual Cost Burden (Dollars)	20,745	0	0	20,745	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 form was flagged as a USMS form that was already in use but without any OMB Control Number associated with it, therefore in violation of the PRA. This submission is an attempt to get it into compliance.

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Annual Cost to Federal Government: $20,745

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 08/07/2018

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