DOI Access & Consent Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DI-4017 CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PRIVACY ACT	Form and Instruction	New	Available
Form DI-4017 DI-4017, Consent for Disclosure of Records Protected under the Privacy Act	Form	New	Repair queued
Form DI-4016 REQUEST FOR INDIVIDUAL ACCESS TO RECORDS PROTECTED UNDER THE PRIVACY ACT	Form and Instruction	New	Repair queued
Form DI-4016 DI-4016, Request for Individual Access to Records Protected under the Privacy Act,	Form	New	Repair queued
1093-NEW - Supporting Statement A (508)_Access and Consent Forms.docx	Supporting Statement A	Uploaded 2022-10-21	Repair queued
PUBLISHED ICR 1093-NEW (87 FR 64085).pdf	Supplementary Document	Uploaded 2022-10-21	Repair queued
SORN - FWS 5.pdf	Supplementary Document	Uploaded 2022-10-21	Repair queued
M-21-04.pdf	Supplementary Document	Uploaded 2022-10-21	Repair queued
PLAW-116publ50.pdf	Supplementary Document	Uploaded 2022-10-21	Repair queued
PUBLISHED ICR 1093-NEW (87 FR 25289).pdf	Supplementary Document	Uploaded 2022-10-21	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
256548	DI-4017, Consent for Disclosure of Records Protected under the Privacy Act	Form and Instruction	New	CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PRIVACY ACT
256548	DI-4017, Consent for Disclosure of Records Protected under the Privacy Act	Form	New
256546	DI-4016, Request for Individual Access to Records Protected under the Privacy Act,	Form and Instruction	New	REQUEST FOR INDIVIDUAL ACCESS TO RECORDS PROTECTED UNDER THE PRIVACY ACT
256546	DI-4016, Request for Individual Access to Records Protected under the Privacy Act,	Form	New

ICR Details

OMB Control No: 1093-0013	ICR Reference No: 202210-1093-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOI/OS	Agency Tracking No:
Title: DOI Access & Consent Forms
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/10/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/21/2022
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved. In accordance with 1320.5(a), the agency is reminded that an agency cannot collect information without a valid OMB control number.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2026	36 Months From Approved
Responses	1,325	0	0
Time Burden (Hours)	332	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Department of the Interior (DOI) developed the DI-4016, Request for Individual Access to Records Protected under the Privacy Act, and DI-4017, Consent for Disclosure of Records Protected under the Privacy Act, forms for individuals to submit requests for accessing, and consenting to the disclosure of, records protected under the Privacy Act of 1974, as amended, 5 U.S.C. 552a. The DI-4016, Request for Individual Access to Records Protected under the Privacy Act, form is used by individuals seeking access to their records and any information pertaining to them that are maintained in DOI’s systems of records. The DI-4017, Consent for Disclosure of Records Protected under the Privacy Act, form provides written consent of the individual to whom the record pertains when disclosing records to another person or an agency. The Privacy Act provides that "the parent of any minor, or the legal guardian of any individual who has been declared to be incompetent due to physical or mental incapacity or age by a court of competent jurisdiction, may act on behalf of the individual.” Therefore, these forms may also be used by a parent or legal guardian. These forms were based on the templates provided in the OMB Memorandum M-21-04, Modernizing Access to and Consent for Disclosure of Records Subject to the Privacy Act, issued on November 12, 2020, which implements the requirements of the Creating Advanced Streamlined Electronic Services for Constituents Act of 2019 (“CASES Act”). The CASES Act was issued in an effort to modernize the Privacy Act request process by requiring agencies to accept access and consent forms from individuals properly identity-proofed and authenticated remotely through a digital service option in addition to an agency’s existing process. The CASES Act also requires the forms to be posted on the agency website's privacy program page and the website updated to include instructions on how individuals may submit requests digitally.

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Authorizing Statute(s): PL: Pub.L. 116 - 50 3 Name of Law: Creating Advanced Streamlined Electronic Services for Constituents Act of 2019 (CASES Act)
  

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:
	87 FR 25289	04/28/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 64085	10/21/2022
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
DI-4016, Request for Individual Access to Records Protected under the Privacy Act,	DI-4016	REQUEST FOR INDIVIDUAL ACCESS TO RECORDS PROTECTED UNDER THE PRIVACY ACT
DI-4017, Consent for Disclosure of Records Protected under the Privacy Act	DI-4017	CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PRIVACY ACT

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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	1,325	0	0	0	0	1,325
Annual Time Burden (Hours)	332	0	0	0	0	332
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: $437,250

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.     Yes

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: 10/21/2022

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