Information Collection

Representative Beneficiary Sample

IC 254364 under ICR 202206-0960-011 · OMB 0960-0827.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment A - NBS Round 8 Instrument.pdf	Other-Representative Beneficiary and
Attachment A - NBS Round 8 Instrument.pdf	Other-Representative Beneficiary and
Attachment C - Paper-Based NBS Instrument for Experiment.pdf	Other-Paper-based NBS Instrument for
Attachment C - Paper-Based NBS Instrument for Experiment.pdf	Other-Paper-based NBS Instrument for
Attachment D - Respondent Correspondence.pdf	Other-Respondnet Coorespondence
Attachment D - Respondent Correspondence.pdf	Other-Respondnet Coorespondence
Attachment E - Confidentiality Pledge.pdf	Other-Confidentiality Pledge
Attachment E - Confidentiality Pledge.pdf	Other-Confidentiality Pledge

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Representative Beneficiary and Successful Worker Combined Questionnaire	Attachment A - NBS Round 8 Instrument.pdf	No	Paper Only
Other-Paper-based NBS Instrument for Experiment	Attachment C - Paper-Based NBS Instrument for Experiment.pdf	No	Paper Only
Other-Respondnet Coorespondence	Attachment D - Respondent Correspondence.pdf	No	Paper Only
Other-Confidentiality Pledge	Attachment E - Confidentiality Pledge.pdf	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	9,583	9,583
Annual IC Cost Burden (Dollars)	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.