Information Collection

Request and Consent Forms for Privacy Records

IC 257943 under ICR 202301-0503-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD 3123 Request and Consent Forms for Privacy Records	Form
AD 3123 Privacy Act Consent Form AD-3123- Privacy Act Consent Form-AH 12 Jan 2023 FINAL.pdf	Form
AD 3123 Privacy Act Consent Form AD-3123- Privacy Act Consent Form-AH 12 Jan 2023 FINAL.pdf	Form
AD-3124 Privacy Act Request Form AD-3124 - Privacy Act Request Form-AH 12 Jan 2023 FINAL.pdf	Form
AD-3124 Privacy Act Request Form AD-3124 - Privacy Act Request Form-AH 12 Jan 2023 FINAL.pdf	Form

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AD 3123	Privacy Act Consent Form	AD-3123- Privacy Act Consent Form-AH 12 Jan 2023 FINAL.pdf		Yes	Yes	Fillable Fileable
Form	AD-3124	Privacy Act Request Form	AD-3124 - Privacy Act Request Form-AH 12 Jan 2023 FINAL.pdf		Yes	Yes	Fillable Fileable

Line of Business: Natural Resources

Subfunction: Agricultural Innovation and Services

Privacy Act System of Records

Title: USDA/OCIO-01 - Freedom of Information Act Express

FR Citation: 83 FR 14283

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	240	240
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.