Information Collection

Tear-off Sheet, Voluntary Disability Disclosure

IC 200928 under ICR 202104-1205-001 · OMB 1205-0223.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0223 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ETA 671 Tear-off Sheet, Voluntary Disability Disclosure	Form and Instruction
ETA 671 Voluntary Disability Disclosure ETA Form 671 Tear off Voluntary Disability Disclosure 042721.docx	Form and Instruction
ETA 671 Voluntary Disability Disclosure ETA Form 671 Tear off Voluntary Disability Disclosure 042721.docx	Form and Instruction

IC Title:

Tear-off Sheet, Voluntary Disability Disclosure

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ETA 671	Voluntary Disability Disclosure	ETA Form 671 Tear off Voluntary Disability Disclosure 042721.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: 252,271

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	252,271	116,799	135,472
Annual IC Time Burden (Hours)	146,317	135,073	11,244
Annual IC Cost Burden (Dollars)	0	0	0

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.