Information Collection

Retaining Employment and Talent after Injury/Illness Network (RETAIN) Demonstration Projects and Evaluation

IC 235436 under ICR 201911-1230-001 · OMB 1230-0014.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1230-0014 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
RETAIN Baseline Participant Form Part 1.docx	Other-Survey
RETAIN Baseline Participant Form Part 2.docx	Other-Survey
RETAIN SSA Authori RETAIN SSA Authorization of Disclosure Form RETAIN SSA Authorization of Disclosure Form.docx	Form and Instruction
Spanish version of Spanish version of Disclosure Form Spanish RETAIN SSA Authorization of Disclosure Form FINAL.DOCX	Form and Instruction

IC Title:

Retaining Employment and Talent after Injury/Illness Network (RETAIN) Demonstration Projects and Evaluation

Agency IC Tracking Number:

201803-0320-001

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey			RETAIN Baseline Participant Form Part 1.docx	Yes	Yes	Fillable Fileable
Other-Survey			RETAIN Baseline Participant Form Part 2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	RETAIN SSA Authorization of Disclosure Form	RETAIN SSA Authorization of Disclosure Form	RETAIN SSA Authorization of Disclosure Form.docx	Yes	Yes	Fillable Printable
Form and Instruction	Spanish version of Disclosure Form	Spanish version of Disclosure Form	Spanish RETAIN SSA Authorization of Disclosure Form FINAL.DOCX	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,333

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5,333	5,333
Annual IC Time Burden (Hours)	1,778	1,778
Annual IC Cost Burden (Dollars)	146,817	146,817

Documents for IC

table that charts IC Documents
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.