Organ Procurement and Transplantation Network Application Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 17 Membership_Individual Form.docx	Form and Instruction	Unchanged	Available
Form 17 OPTN Individual Membership Application	Form and Instruction	Unchanged	Repair queued
Form 16 Membership_Business Form.docx	Form and Instruction	Unchanged	Available
Form 16 OPTN Business Membership Application	Form and Instruction	Unchanged	Available
Form 15 Membership_PublicOrg Form.docx	Form and Instruction	Unchanged	Available
Form 15 OPTN Public Organization Membership Application	Form and Instruction	Unchanged	Repair queued
Form 14 Membership_MedicalScientific Form.docx	Form and Instruction	Unchanged	Available
Form 14 OPTN Medical Scientific Membership Application	Form and Instruction	Unchanged	Repair queued
Form 13 Membership_Representative Form.docx	Form and Instruction	Unchanged	Available
Form 13 OPTN Representative Form	Form and Instruction	Unchanged	Repair queued
Form 12 R OPTN Membership Application for Histocompatibility Laboratories REDLINE	Form and Instruction	Modified	Available
Form 12 OPTN Membership Application for Histocompatibility Laboratories CLEAN	Form and Instruction	Modified	Available
Form 12 OPTN Membership Application for Histocompatibility Labs	Form and Instruction	Unchanged	Available
Form 11 Membership_OPO Form.docx	Form and Instruction	Unchanged	Available
Form 11 OPTN Membership Application for OPOs	Form and Instruction	Unchanged	Repair queued
Form 10 BR OPTN Membership Application_Surgeon or Physician Log REDLINE	Form and Instruction	Modified	Available
Form 10 B OPTN Membership Application_Surgeon or Physician Log CLEAN	Form and Instruction	Modified	Available
Form 10 R OPTN Membership Application for Intestine Transplant Programs REDLINE	Form and Instruction	Modified	Repair queued
Form 10 OPTN Membership Application for Intestine Transplant Programs CLEAN	Form and Instruction	Modified	Available
Form 10 OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Unchanged	Available
Form 2 Membership_CertificateAssessment_ProgramCoverage Form.docx	Form and Instruction	Unchanged	Available
Form 2 OPTN Certificate of Assessment and Program Coverage Plan Membership Application	Form and Instruction	Unchanged	Available
Form 9 BR OPTN Membership Application_Surgeon or Physician Log REDLINE	Form and Instruction	Modified	Available
Form 9 B OPTN Membership Application_Surgeon or Physician Log CLEAN	Form and Instruction	Modified	Available
Form 9 R OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs REDLINE	Form and Instruction	Modified	Repair queued
Form 9 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs CLEAN	Form and Instruction	Modified	Repair queued
Form 9 OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Unchanged	Available
Form 8 BR OPTN Membership Application_Surgeon or Physician Log REDLINE	Form and Instruction	Modified	Repair queued
Form 8 B OPTN Membership Application_Surgeon or Physician Log CLEAN	Form and Instruction	Modified	Available
Form 8 R OPTN Membership Application for Islet Transplant Programs REDLINE	Form and Instruction	Modified	Available
Form 8 OPTN Membership Application for Islet Transplant Programs CLEAN	Form and Instruction	Modified	Available
Form 8 OPTN Membership Application Islet Transplant Program	Form and Instruction	Unchanged	Repair queued
Form 7 BR OPTN Membership Application_Surgeon or Physician Log REDLINE	Form and Instruction	Modified	Available
Form 7 B OPTN Membership Application_Surgeon or Physician Log CLEAN	Form and Instruction	Modified	Available
Form 7 R OPTN Membership Application for Lung Transplant Programs REDLINE	Form and Instruction	Modified	Available
Form 7 OPTN Membership Application for Lung Transplant Programs CLEAN	Form and Instruction	Modified	Repair queued
Form 7 OPTN Membership Application for Lung Transplant Program	Form and Instruction	Unchanged	Repair queued
Form 6 BR OPTN Membership Application_Surgeon or Physician Log REDLINE	Form and Instruction	Modified	Available
Form 6 B OPTN Membership Application_Surgeon or Physician Log CLEAN	Form and Instruction	Modified	Available
Form 6 R OPTN Membership Application for Heart Transplant Programs REDLINE	Form and Instruction	Modified	Available
Form 6 OPTN Membership Application for Heart Transplant Programs CLEAN	Form and Instruction	Modified	Available
Form 6 OPTN Membership Application for Heart Transplant Program	Form and Instruction	Unchanged	Available
Form 5 BR OPTN Membership Application_Surgeon or Physician Log REDLINE	Form and Instruction	Modified	Available
Form 5 B OPTN Membership Application_Surgeon or Physician Log CLEAN	Form and Instruction	Modified	Available
Form 5 R OPTN Membership Application for Pancreas Transplant Programs REDLINE	Form and Instruction	Modified	Available
Form 5 OPTN Membership Application for Pancreas Transplant Programs CLEAN	Form and Instruction	Modified	Available
Form 5 OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Unchanged	Repair queued
Form 4 BR OPTN Membership Application_Surgeon or Physician Log REDLINE.docx	Form and Instruction	Modified	Available
Form 4 B OPTN Membership Application_Surgeon or Physician Log CLEAN	Form and Instruction	Modified	Available
Form 4 R OPTN Membership Application for Liver Transplant Programs REDLINE	Form and Instruction	Modified	Available
Form 4 OPTN Membership Application for Liver Transplant Programs CLEAN	Form and Instruction	Modified	Available
Form 4 OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Unchanged	Available
Form 3 BR OPTN Membership Application_Surgeon or Physician Log REDLINE.docx	Form and Instruction	Modified	Available
Form 3 B OPTN Membership Application_Surgeon or Physician Log CLEAN.docx	Form and Instruction	Modified	Available
Form 3 R OPTN Membership Application for Kidney Transplant Programs REDLINE	Form and Instruction	Modified	Repair queued
Form 3 OPTN Membership Application for Kidney Transplant Programs CLEAN	Form and Instruction	Modified	Repair queued
Form 3 OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Unchanged	Available
Form 1 R OPTN Membership Application for Transplant Hospitals and Programs REDLINE.docx	Form and Instruction	Modified	Repair queued
Form 1 OPTN Membership Application for Transplant Hospitals and Programs CLEAN.docx	Form and Instruction	Modified	Available
Form 1 OPTN Membership Application for Transplant Hospitals	Form and Instruction	Unchanged	Repair queued
05272021 - OPTN Membership Application for Heart Transplant Programs - REDLINE.docx	Supplementary Document	Uploaded 2021-06-02	Available
05272021 - OPTN Membership Application for Heart Transplant Programs - CLEAN.docx	Supplementary Document	Uploaded 2021-06-02	Repair queued
FINAL Change Memo - OPTN Membership Forms - 0915-0184.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-06-02	Repair queued
FINAL Supporting Statement - 0915-0184.docx	Supporting Statement A	Uploaded 2020-06-26	Repair queued
60-Day OPTN FRN OMB No. 0915-0184.Published.pdf	Supplementary Document	Uploaded 2020-06-26	Available
Names_Crosswalk.xlsx	Supplementary Document	Uploaded 2020-06-26	Available
05.19.2020 Summary of Changes - OPTN 0915-0184.docx	Supplementary Document	Uploaded 2020-06-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
226701	OPTN Individual Membership Application	Form and Instruction	Unchanged	Membership_Individual Form.docx
226701	OPTN Individual Membership Application	Form and Instruction	Unchanged
226700	OPTN Business Membership Application	Form and Instruction	Unchanged	Membership_Business Form.docx
226700	OPTN Business Membership Application	Form and Instruction	Unchanged
226699	OPTN Public Organization Membership Application	Form and Instruction	Unchanged	Membership_PublicOrg Form.docx
226699	OPTN Public Organization Membership Application	Form and Instruction	Unchanged
226698	OPTN Medical Scientific Membership Application	Form and Instruction	Unchanged	Membership_MedicalScientific Form.docx
226698	OPTN Medical Scientific Membership Application	Form and Instruction	Unchanged
226695	OPTN Representative Form	Form and Instruction	Unchanged	Membership_Representative Form.docx
226695	OPTN Representative Form	Form and Instruction	Unchanged
226694	OPTN Membership Application for Histocompatibility Labs	Form and Instruction	Modified	OPTN Membership Application for Histocompatibility Laboratories REDLINE
226694	OPTN Membership Application for Histocompatibility Labs	Form and Instruction	Modified	OPTN Membership Application for Histocompatibility Laboratories CLEAN
226694	OPTN Membership Application for Histocompatibility Labs	Form and Instruction	Unchanged
226693	OPTN Membership Application for OPOs	Form and Instruction	Unchanged	Membership_OPO Form.docx
226693	OPTN Membership Application for OPOs	Form and Instruction	Unchanged
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log REDLINE
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log CLEAN
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	OPTN Membership Application for Intestine Transplant Programs REDLINE
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Modified	OPTN Membership Application for Intestine Transplant Programs CLEAN
226692	OPTN Membership Application for Intestine Transplant Programs	Form and Instruction	Unchanged
226689	OPTN Certificate of Assessment and Program Coverage Plan Membership Application	Form and Instruction	Unchanged	Membership_CertificateAssessment_ProgramCoverage Form.docx
226689	OPTN Certificate of Assessment and Program Coverage Plan Membership Application	Form and Instruction	Unchanged
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log REDLINE
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log CLEAN
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs REDLINE
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Modified	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs CLEAN
226687	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	Form and Instruction	Unchanged
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log REDLINE
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log CLEAN
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified	OPTN Membership Application for Islet Transplant Programs REDLINE
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Modified	OPTN Membership Application for Islet Transplant Programs CLEAN
226686	OPTN Membership Application Islet Transplant Program	Form and Instruction	Unchanged
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log REDLINE
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log CLEAN
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified	OPTN Membership Application for Lung Transplant Programs REDLINE
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Modified	OPTN Membership Application for Lung Transplant Programs CLEAN
226685	OPTN Membership Application for Lung Transplant Program	Form and Instruction	Unchanged
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log REDLINE
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log CLEAN
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified	OPTN Membership Application for Heart Transplant Programs REDLINE
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Modified	OPTN Membership Application for Heart Transplant Programs CLEAN
226684	OPTN Membership Application for Heart Transplant Program	Form and Instruction	Unchanged
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log REDLINE
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log CLEAN
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	OPTN Membership Application for Pancreas Transplant Programs REDLINE
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Modified	OPTN Membership Application for Pancreas Transplant Programs CLEAN
226683	OPTN Membership Application for Pancreas Transplant Programs	Form and Instruction	Unchanged
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log REDLINE.docx
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log CLEAN
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified	OPTN Membership Application for Liver Transplant Programs REDLINE
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Modified	OPTN Membership Application for Liver Transplant Programs CLEAN
226682	OPTN Membership Application for Liver Transplant Progrms	Form and Instruction	Unchanged
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log REDLINE.docx
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	OPTN Membership Application_Surgeon or Physician Log CLEAN.docx
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	OPTN Membership Application for Kidney Transplant Programs REDLINE
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Modified	OPTN Membership Application for Kidney Transplant Programs CLEAN
226681	OPTN Membership Application for Kidney Transplant Programs	Form and Instruction	Unchanged
226680	OPTN Membership Application for Transplant Hospitals and Programs	Form and Instruction	Modified	OPTN Membership Application for Transplant Hospitals and Programs REDLINE.docx
226680	OPTN Membership Application for Transplant Hospitals and Programs	Form and Instruction	Modified	OPTN Membership Application for Transplant Hospitals and Programs CLEAN.docx
226680	OPTN Membership Application for Transplant Hospitals	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0915-0184	ICR Reference No: 202106-0915-002
Status: Historical Active	Previous ICR Reference No: 202006-0915-007
Agency/Subagency: HHS/HSA	Agency Tracking No: 21566
Title: Organ Procurement and Transplantation Network Application Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/05/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/02/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2023	08/31/2023	08/31/2023
Responses	1,661	0	1,661
Time Burden (Hours)	4,755	0	4,755
Cost Burden (Dollars)	0	0	0

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Abstract: This is a request for OMB approval for revisions of the application documents used to collect information for determining if the interested party is compliant with membership requirements contained in the final rule Governing the Operation of the Organ Procurement and Transplantation Network (OPTN), (42 CFR part 121) ‘‘the OPTN final rule.’’ Respondents include: hospitals seeking to perform organ transplants, non-profit organizations seeking to become an organ procurement organization, and medical laboratories seeking to become an OPTN-approved histocompatibility laboratory.

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Authorizing Statute(s): US Code: 42 USC 273 Name of Law: National Organ Transplant Act of 1984
   US Code: 42 USC 1138 Name of Law: Hospital Protocols for Organ Procurement and Standards for Organ Procurement Agencies
  

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:
	85 FR 8300	02/13/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 38380	06/26/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 17

table that charts list of burden

IC Title	Form No.	Form Name
OPTN Business Membership Application	16	Membership_Business Form.docx
OPTN Certificate of Assessment and Program Coverage Plan Membership Application	2	Membership_CertificateAssessment_ProgramCoverage Form.docx
OPTN Individual Membership Application	17	Membership_Individual Form.docx
OPTN Medical Scientific Membership Application	14	Membership_MedicalScientific Form.docx
OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Program Application	9 , 9 R, 9 B, 9 BR	OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs CLEAN ,   OPTN Membership Application for Vascularized Composite Allograft (VCA) Transplant Programs REDLINE ,   OPTN Membership Application_Surgeon or Physician Log CLEAN ,   OPTN Membership Application_Surgeon or Physician Log REDLINE
OPTN Membership Application Islet Transplant Program	8, 8 R, 8 B, 8 BR	OPTN Membership Application for Islet Transplant Programs CLEAN ,   OPTN Membership Application for Islet Transplant Programs REDLINE ,   OPTN Membership Application_Surgeon or Physician Log CLEAN ,   OPTN Membership Application_Surgeon or Physician Log REDLINE
OPTN Membership Application for Heart Transplant Program	6 B, 6, 6 R, 6 BR	OPTN Membership Application for Heart Transplant Programs CLEAN ,   OPTN Membership Application for Heart Transplant Programs REDLINE ,   OPTN Membership Application_Surgeon or Physician Log CLEAN ,   OPTN Membership Application_Surgeon or Physician Log REDLINE
OPTN Membership Application for Histocompatibility Labs	12, 12 R	OPTN Membership Application for Histocompatibility Laboratories CLEAN ,   OPTN Membership Application for Histocompatibility Laboratories REDLINE
OPTN Membership Application for Intestine Transplant Programs	10, 10 R, 10 B, 10 BR	OPTN Membership Application for Intestine Transplant Programs CLEAN ,   OPTN Membership Application for Intestine Transplant Programs REDLINE ,   OPTN Membership Application_Surgeon or Physician Log CLEAN ,   OPTN Membership Application_Surgeon or Physician Log REDLINE
OPTN Membership Application for Kidney Transplant Programs	3 B, 3 BR, 3 R, 3	OPTN Membership Application for Kidney Transplant Programs CLEAN ,   OPTN Membership Application for Kidney Transplant Programs REDLINE ,   OPTN Membership Application_Surgeon or Physician Log CLEAN.docx ,   OPTN Membership Application_Surgeon or Physician Log REDLINE.docx
OPTN Membership Application for Liver Transplant Progrms	4, 4 R, 4 B, 4 BR	OPTN Membership Application for Liver Transplant Programs CLEAN ,   OPTN Membership Application for Liver Transplant Programs REDLINE ,   OPTN Membership Application_Surgeon or Physician Log CLEAN ,   OPTN Membership Application_Surgeon or Physician Log REDLINE.docx
OPTN Membership Application for Lung Transplant Program	7, 7 R, 7 B, 7 BR	OPTN Membership Application for Lung Transplant Programs CLEAN ,   OPTN Membership Application for Lung Transplant Programs REDLINE ,   OPTN Membership Application_Surgeon or Physician Log CLEAN ,   OPTN Membership Application_Surgeon or Physician Log REDLINE
OPTN Membership Application for OPOs	11	Membership_OPO Form.docx
OPTN Membership Application for Pancreas Transplant Programs	5, 5 R, 5 B, 5 BR	OPTN Membership Application for Pancreas Transplant Programs CLEAN ,   OPTN Membership Application for Pancreas Transplant Programs REDLINE ,   OPTN Membership Application_Surgeon or Physician Log CLEAN ,   OPTN Membership Application_Surgeon or Physician Log REDLINE
OPTN Membership Application for Transplant Hospitals and Programs	1, 1 R	OPTN Membership Application for Transplant Hospitals and Programs CLEAN.docx ,   OPTN Membership Application for Transplant Hospitals and Programs REDLINE.docx
OPTN Public Organization Membership Application	15	Membership_PublicOrg Form.docx
OPTN Representative Form	13	Membership_Representative Form.docx

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ICR Summary of Burden

table that charts list 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	1,661	1,661	0	0	0	0
Annual Time Burden (Hours)	4,755	4,755	0	0	0	0
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: $345,000

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.     No

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.     No

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? No

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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: 06/02/2021

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