Crisis Assistance Request Form - Ukraine

Forms and Documents

Document Name	Status
Crisis Assistance Request Form - Ukraine Form and Instruction	New
Justification for Emergency Review - Ukraine form (final).docx Supplementary Document	2022-02-28
Ukraine Crisis Form - Legal Authorities (2-28-22) - Copy.docx Supplementary Document	2022-02-28
Supporting Statement - Ukraine form (final).docx Supporting Statement A	2022-02-28

IC Document Collections

IC ID	Document Title	Status
251891	Crisis Assistance Request Form - Ukraine Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202202-1405-009
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Crisis Assistance Request Form - Ukraine
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 03/04/2022
Date Submitted to OIRA: 02/28/2022

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	7,000	0
Time Burden (Hours)	583	0
Cost Burden (Dollars)	0	0

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Abstract: The purpose of the collection is to enable the Department of State to better communicate with U.S. citizens and lawful permanent residents (LPRs) who may be in need of assistance in departing Ukraine, amid continued Russian efforts to destabilize the country and undermine the security of Ukrainian citizens and others visiting or residing in Ukraine.

Emergency Justfication: On January 23, the U.S. Department of State authorized the voluntary departure of non-emergency U.S. government employees. At the same time, the Department ordered departure of family members of U.S. government employees at the U.S. Embassy in Kyiv. Additionally, Department elevated our previous Travel Advisory for Ukraine to Level Four – Do Not Travel due to the increased threats of Russian military action. (The Travel Advisory was already at Level Four – Do Not Travel due to COVID-19.) The Department took these actions out of an abundance of caution due to continued Russian efforts to destabilize the country and undermine the security of Ukrainian citizens and others visiting or residing in Ukraine.

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Authorizing Statute(s): EO: EO 12656 Name/Subject of EO: Assignment of Emergency Preparedness Responsibilities (1998)
  

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

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
Crisis Assistance Request Form - Ukraine	NA	Ukraine Crisis Intake Form

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ICR Summary of Burden

	Total Request	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	7,000	0	0	7,000	0	0
Annual Time Burden (Hours)	583	0	0	583	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: Please see supporting statement.

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Annual Cost to Federal Government: $0

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.     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: 02/28/2022

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