PFPA Recruitment, Medical, and Fitness Forms

Forms and Documents

Document Name	Status
Form PFPA Form 1408 1. Application Status Request (PFPA Form 1408) Form and Instruction	New
Form PFPA Form 1409 Character Reference Questionnaire (PFPA Form 1409) Form and Instruction	New
Form PFPA Form 1410 Employer Reference Questionnaire (PFPA Form 1410) Form and Instruction	New
Form PFPA Form 1407 Internal Affairs Request (PFPA Form 1407) Form and Instruction	New
Form PFPA Form 6040 Supplemental Medical History Questionnaire (PFPA Form 6040) Form and Instruction	New
Form PFPA Form 1400 Authorization for Release of Information (PFPA Form 1400) Form and Instruction	New
SSN Justification Memorandum.PDF Supplementary Document	2019-06-10
0704-AABZ SSA 10.25.2019.docx Supporting Statement A	2019-10-25

IC Document Collections

IC ID	Document Title	Status
236337	1. Application Status Request (PFPA Form 1408) Form and Instruction	New
236336	Character Reference Questionnaire (PFPA Form 1409) Form and Instruction	New
236262	Employer Reference Questionnaire (PFPA Form 1410) Form and Instruction	New
236260	Internal Affairs Request (PFPA Form 1407) Form and Instruction	New
236253	Supplemental Medical History Questionnaire (PFPA Form 6040) Form and Instruction	New
236251	Authorization for Release of Information (PFPA Form 1400) Form and Instruction	New

ICR Details

OMB Control No: 0704-0588	ICR Reference No: 201905-0704-007
Status: Active	Previous ICR Reference No:
Agency/Subagency: DOD/DODDEP	Agency Tracking No: 0704-AABZ
Title: PFPA Recruitment, Medical, and Fitness Forms
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 with change	Conclusion Date: 11/22/2019
	Date Received in OIRA: 06/11/2019
Terms of Clearance: This collection is approved based on the revised materials provided by the Department.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2022	36 Months From Approved
Responses	3,600	0	0
Time Burden (Hours)	520	0	0
Cost Burden (Dollars)	14,040	0	0

---

Abstract: This information collection is essential to PFPA and is used to make a determination of fitness for federal employment in the field of law enforcement. To that end, criminal, background and medical information is collected on the applicants.

---

Authorizing Statute(s): US Code: 5 USC 3304 Name of Law: Competitive service; examinations
   US Code: 5 USC 3318 Name of Law: Competitive service; selection from certificates
   US Code: 5 USC 9101 Name of Law: Access to criminal history records for national security and other purposes
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 42884	08/24/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 26821	06/10/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
1. Application Status Request (PFPA Form 1408)	PFPA Form 1408	Application Status Request
Character Reference Questionnaire (PFPA Form 1409)	PFPA Form 1409	Character Reference Questionnaire
Supplemental Medical History Questionnaire (PFPA Form 6040)	PFPA Form 6040	Supplemental Medical History Questionnaire
Authorization for Release of Information (PFPA Form 1400)	PFPA Form 1400	Authorization for Release of Information
Internal Affairs Request (PFPA Form 1407)	PFPA Form 1407	Internal Affairs Request
Employer Reference Questionnaire (PFPA Form 1410)	PFPA Form 1410	Employer Reference Questionnaire

---

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	3,600	0	0	3,600	0	0
Annual Time Burden (Hours)	520	0	0	520	0	0
Annual Cost Burden (Dollars)	14,040	0	0	14,040	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 is a new collection.

---

Annual Cost to Federal Government: $313,182

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

---

Common Form ICR:  No

---

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: 06/11/2019

---