Disabled Dependent Questionnaire

Forms and Documents

Document Name	Status
Form RI 30-10 Disabled Dependent Questionnaire Form and Instruction	Modified
ARS PIA Final 12212017signed.pdf Supplementary Document	2018-02-02
RI30-010_Regs.pdf Supplementary Document	2018-02-02
RI30-010_30dayFRNPublished_2018_01_03.pdf Supplementary Document	2018-02-02
RI30-010_60DayFRN_Published_2017_05_05.pdf Supplementary Document	2018-02-02
RI30-010_OMBSupportingStmt_2018_05_30.docx Supporting Statement A	2018-05-30

IC Document Collections

IC ID	Document Title	Status
33661	Disabled Dependent Questionnaire Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0179	ICR Reference No: 201802-3206-001
Status: Active	Previous ICR Reference No: 201603-3206-010
Agency/Subagency: OPM	Agency Tracking No: RI 30-10
Title: Disabled Dependent Questionnaire
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/04/2018
	Date Received in OIRA: 02/22/2018
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency. OPM must report this collection as part of the information collection budget. In addition, before this collection is next submitted to OMB for approval, OPM should consider if it should be a common form as it appears to be a information collection in use government-wide for the same purpose.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	36 Months From Approved
Responses	2,500	0	0
Time Burden (Hours)	2,500	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: RI 30-10 collects sufficient information about the medical condition and earning capacity for OPM to determine whether a disabled adult child is eligible for health benefits coverage and/or survivor annuity payments under the Civil Service Retirement System or the Federal Employees Retirement System.

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Authorizing Statute(s): US Code: 5 USC 8341(a)(4)(B) Name of Law: CSRS, Survivor Annuities
   US Code: 5 USC 8441(4)(B) Name of Law: FERS, Definitions
  

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 21275	05/05/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 404	01/03/2018
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
Disabled Dependent Questionnaire	RI 30-10, RI 30-10	Disabled Dependent Questionnaire ,   Disabled Dependent 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	2,500	0	0	0	0	2,500
Annual Time Burden (Hours)	2,500	0	0	0	0	2,500
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $7,725

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: 02/22/2018

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