Request and Consent Forms for Privacy Records

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form AD-3124 Privacy Act Request Form	Form	New	Available
Form AD 3123 Privacy Act Consent Form	Form	New	Available
Form AD 3123 Request and Consent Forms for Privacy Records	Form	New	Repair queued
SuptStmt 11 Jan 2023 pp.docx	Supporting Statement A	Uploaded 2023-01-23	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
257943	Request and Consent Forms for Privacy Records	Form	New	Privacy Act Request Form
257943	Request and Consent Forms for Privacy Records	Form	New	Privacy Act Consent Form
257943	Request and Consent Forms for Privacy Records	Form	New

ICR Details

OMB Control No:	ICR Reference No: 202301-0503-001
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: USDA/AgSEC	Agency Tracking No:
Title: Request and Consent Forms for Privacy Records
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 02/23/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/23/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: To modernize the processes by which individuals may request access to, and consent to the disclosure of records under the Privacy Act of 1974.

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Authorizing Statute(s): None

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 64199	10/24/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 3966	01/23/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Request and Consent Forms for Privacy Records	AD 3123, AD-3124	Privacy Act Consent Form ,   Privacy Act Request Form

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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: This is a new collection of information resulting in a program change of 240 burden hours.

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Annual Cost to Federal Government:

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: 01/23/2023

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