HIRE Vets Medallion Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1293-0015 can be found here:

Documents and Forms

Document Name Document Type
Form VETS-1011LG HIRE Vets Medallion Program Form and Instruction
VETS-1011LG HIRE Vets Medallion Award Application Large Employer - G Medallion PDF Application Form (10.0_LG) (with instruction pages)gt2.pdf Form and Instruction
VETS-1011LP HIRE Vets Medallion Award ApplicationLarge Employer - Pl Medallion PDF Application Form (10.0_LP) (with instruction pages)gt2.pdf Form and Instruction
VETS -1011MG HIRE Vets Medallion Award Application Medium Employer - Medallion PDF Application Form (10.0_MG) (with instruction pages)gt2.pdf Form and Instruction
VETS-1011MP HIRE Vets Medallion Award Application Medium Employer - Medallion PDF Application Form (10.0_MP) (with instruction pages)gt2.pdf Form and Instruction
VETS-1011SG HIRE Vets Medallion Award Application Small Employer - G Medallion PDF Application Form (10.0_SG) (with instruction pages)gt2.pdf Form and Instruction
VETS-1011SP HIRE Vets Medallion Award Application Small Employer - P Medallion PDF Application Form (10.0_SP) (with instruction pages)gt2.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HIRE Vets Medallion Program	Agency IC Tracking Number:	1293-0New(HIRE)

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR part 2011, subpart B (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	VETS-1011LG	HIRE Vets Medallion Award Application Large Employer - Gold Award	Medallion PDF Application Form (10.0_LG) (with instruction pages)gt2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	VETS-1011LP	HIRE Vets Medallion Award ApplicationLarge Employer - Platinum Award	Medallion PDF Application Form (10.0_LP) (with instruction pages)gt2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	VETS -1011MG	HIRE Vets Medallion Award Application Medium Employer - Gold Award	Medallion PDF Application Form (10.0_MG) (with instruction pages)gt2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	VETS-1011MP	HIRE Vets Medallion Award Application Medium Employer - Platinum Award	Medallion PDF Application Form (10.0_MP) (with instruction pages)gt2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	VETS-1011SG	HIRE Vets Medallion Award Application Small Employer - Gold Award	Medallion PDF Application Form (10.0_SG) (with instruction pages)gt2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	VETS-1011SP	HIRE Vets Medallion Award Application Small Employer - Platinum Award	Medallion PDF Application Form (10.0_SP) (with instruction pages)gt2.pdf	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,025	Number of Respondents for Small Entity: 1,011

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	34,184	34,184
Annual IC Time Burden (Hours)	58,556	58,556
Annual IC Cost Burden (Dollars)	1,845,466	1,845,466

Documents for IC

Title	Document	Date Uploaded
No associated records found

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