U.S. Repatriation Program Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - Traditional Chinese	Form and Instruction	Modified	Available
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - Spanish	Form and Instruction	Modified	Available
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - Simplified Chinese	Form and Instruction	Modified	Available
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - Russian	Form and Instruction	Modified	Available
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - French	Form and Instruction	Modified	Available
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - Arabic	Form and Instruction	Modified	Available
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified	Available
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified	Repair queued
Form RR-07 Temporary Assistance Extension Request - Traditional Chinese	Form and Instruction	Modified	Available
Form RR-07 Temporary Assistance Extension Request - Spanish	Form and Instruction	Modified	Available
Form RR-07 Temporary Assistance Extension Request - Simplified Chinese	Form and Instruction	Modified	Available
Form RR-07 Temporary Assistance Extension Request - Russian	Form and Instruction	Modified	Available
Form RR-07 Temporary Assistance Extension Request - French	Form and Instruction	Modified	Available
Form RR-07 Temporary Assistance Extension Request - Arabic	Form and Instruction	Modified	Available
Form RR-07 Temporary Assistance Extension Request	Form and Instruction	Modified	Available
Form RR-07 Temporary Assistance Extension Request	Form and Instruction	Modified	Repair queued
Form RR-06 Refusal of Temporary Assistance - Traditional Chinese	Form and Instruction	Modified	Available
Form RR-06 Refusal of Temporary Assistance - Spanish	Form and Instruction	Modified	Available
Form RR-06 Refusal of Temporary Assistance - Simplified Chinese	Form and Instruction	Modified	Available
Form RR-06 Refusal of Temporary Assistance - Russian	Form and Instruction	Modified	Available
Form RR-06 Refusal of Temporary Assistance - French	Form and Instruction	Modified	Available
Form RR-06 Refusal of Temporary Assistance - Arabic	Form and Instruction	Modified	Available
Form RR-06 Refusal of Temporary Assistance	Form and Instruction	Modified	Available
Form RR-06 Refusal of Temporary Assistance	Form and Instruction	Modified	Repair queued
Form RR-05 Repatriation Repayment and Privacy Agreement - Traditional Chinese	Form and Instruction	Modified	Available
Form RR-05 Repatriation Repayment and Privacy Agreement - Spanish	Form and Instruction	Modified	Available
Form RR-05 Repatriation Repayment and Privacy Agreement - Simplified Chinese	Form and Instruction	Modified	Available
Form RR-05 Repatriation Repayment and Privacy Agreement - Russian	Form and Instruction	Modified	Available
Form RR-05 Repatriation Repayment and Privacy Agreement - French	Form and Instruction	Modified	Available
Form RR-05 Repatriation Repayment and Privacy Agreement - Arabic	Form and Instruction	Modified	Available
Form RR-05 Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified	Available
Form RR-05 Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified	Repair queued
Form RR-04 Routine Repatriation Reimbursement Request - Traditional Chinese	Form and Instruction	Modified	Available
Form RR-04 Routine Repatriation Reimbursement Request - Spanish	Form and Instruction	Modified	Available
Form RR-04 Routine Repatriation Reimbursement Request - Simplified Chinese	Form and Instruction	Modified	Available
Form RR-04 Routine Repatriation Reimbursement Request - Russian	Form and Instruction	Modified	Available
Form RR-04 Routine Repatriation Reimbursement Request - French	Form and Instruction	Modified	Available
Form RR-04 Routine Repatriation Reimbursement Request - Arabic	Form and Instruction	Modified	Available
Form RR-04 Routine Repatriation Reimbursement Request	Form and Instruction	Modified	Available
Form RR-04 Routine Repatriation Reimbursement Request	Form and Instruction	Modified	Repair queued
Form RR-03 Loan Waiver and Deferral Application - Traditional Chinese	Form and Instruction	Modified	Available
Form RR-03 Loan Waiver and Deferral Application - Spanish	Form and Instruction	Modified	Available
Form RR-03 Loan Waiver and Deferral Application - Simplified Chinese	Form and Instruction	Modified	Available
Form RR-03 Loan Waiver and Deferral Application - Russian	Form and Instruction	Modified	Available
Form RR-03 Loan Waiver and Deferral Application - French	Form and Instruction	Modified	Available
Form RR-03 Loan Waiver and Deferral Application - Arabic	Form and Instruction	Modified	Available
Form RR-03 Loan Waiver and Deferral Application	Form and Instruction	Modified	Available
Form RR-03 Loan Waiver and Deferral Application	Form and Instruction	Modified	Repair queued
Form RR-02 Emergency Repatriation Reimbursement Request - Traditional Chinese	Form and Instruction	Modified	Available
Form RR-02 Emergency Repatriation Reimbursement Request - Spanish	Form and Instruction	Modified	Available
Form RR-02 Emergency Repatriation Reimbursement Request - Simplified Chinese	Form and Instruction	Modified	Available
Form RR-02 Emergency Repatriation Reimbursement Request - Russian	Form and Instruction	Modified	Available
Form RR-02 Emergency Repatriation Reimbursement Request - French	Form and Instruction	Modified	Available
Form RR-02 Emergency Repatriation Reimbursement Request - Arabic	Form and Instruction	Modified	Available
Form RR-02 Emergency Repatriation Reimbursement Request	Form and Instruction	Modified	Available
Form RR-02 Emergency Repatriation Reimbursement Request	Form and Instruction	Modified	Repair queued
Form RR-01 Emergency Repatriation Eligibility Application - Traditional Chinese	Form and Instruction	Modified	Available
Form RR-01 Emergency Repatriation Eligibility Application - Spanish	Form and Instruction	Modified	Available
Form RR-01 Emergency Repatriation Eligibility Application - Simplified Chinese	Form and Instruction	Modified	Available
Form RR-01 Emergency Repatriation Eligibility Application - Russian	Form and Instruction	Modified	Available
Form RR-01 Emergency Repatriation Eligibility Application - French	Form and Instruction	Modified	Available
Form RR-01 Emergency Repatriation Eligibility Application - Arabic	Form and Instruction	Modified	Available
Form RR-01 Emergency Repatriation Eligibility Application	Form and Instruction	Modified	Available
Form RR-01 Emergency Repatriation Eligibility Application	Form and Instruction	Modified	Repair queued
NonSub Change Request - Translations - 28 April 2023_fnl.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-04-28	Available
NonSub Change Request - Translations - 28 April 2023_fnl.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-04-28	Repair queued
Supporting Statement A - OHSEPR Repatriation Revision v3.docx	Supporting Statement A	Uploaded 2022-04-07	Available
Supporting Statement A - OHSEPR Repatriation Revision v3.docx	Supporting Statement A	Uploaded 2022-04-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
218660	Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified	Emergency Repatriation Request for Cost Approval and Federal Support - Traditional Chinese
218660	Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified	Emergency Repatriation Request for Cost Approval and Federal Support - Spanish
218660	Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified	Emergency Repatriation Request for Cost Approval and Federal Support - Simplified Chinese
218660	Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified	Emergency Repatriation Request for Cost Approval and Federal Support - Russian
218660	Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified	Emergency Repatriation Request for Cost Approval and Federal Support - French
218660	Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified	Emergency Repatriation Request for Cost Approval and Federal Support - Arabic
218660	Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified	Emergency Repatriation Request for Cost Approval and Federal Support
218660	Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified
218659	Temporary Assistance Extension Request	Form and Instruction	Modified	Temporary Assistance Extension Request - Traditional Chinese
218659	Temporary Assistance Extension Request	Form and Instruction	Modified	Temporary Assistance Extension Request - Spanish
218659	Temporary Assistance Extension Request	Form and Instruction	Modified	Temporary Assistance Extension Request - Simplified Chinese
218659	Temporary Assistance Extension Request	Form and Instruction	Modified	Temporary Assistance Extension Request - Russian
218659	Temporary Assistance Extension Request	Form and Instruction	Modified	Temporary Assistance Extension Request - French
218659	Temporary Assistance Extension Request	Form and Instruction	Modified	Temporary Assistance Extension Request - Arabic
218659	Temporary Assistance Extension Request	Form and Instruction	Modified	Temporary Assistance Extension Request
218659	Temporary Assistance Extension Request	Form and Instruction	Modified
218658	Refusal of Temporary Assistance	Form and Instruction	Modified	Refusal of Temporary Assistance - Traditional Chinese
218658	Refusal of Temporary Assistance	Form and Instruction	Modified	Refusal of Temporary Assistance - Spanish
218658	Refusal of Temporary Assistance	Form and Instruction	Modified	Refusal of Temporary Assistance - Simplified Chinese
218658	Refusal of Temporary Assistance	Form and Instruction	Modified	Refusal of Temporary Assistance - Russian
218658	Refusal of Temporary Assistance	Form and Instruction	Modified	Refusal of Temporary Assistance - French
218658	Refusal of Temporary Assistance	Form and Instruction	Modified	Refusal of Temporary Assistance - Arabic
218658	Refusal of Temporary Assistance	Form and Instruction	Modified	Refusal of Temporary Assistance
218658	Refusal of Temporary Assistance	Form and Instruction	Modified
218657	Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified	Repatriation Repayment and Privacy Agreement - Traditional Chinese
218657	Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified	Repatriation Repayment and Privacy Agreement - Spanish
218657	Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified	Repatriation Repayment and Privacy Agreement - Simplified Chinese
218657	Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified	Repatriation Repayment and Privacy Agreement - Russian
218657	Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified	Repatriation Repayment and Privacy Agreement - French
218657	Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified	Repatriation Repayment and Privacy Agreement - Arabic
218657	Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified	Repatriation Repayment and Privacy Agreement
218657	Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified
218656	Routine Repatriation Reimbursement Request	Form and Instruction	Modified	Routine Repatriation Reimbursement Request - Traditional Chinese
218656	Routine Repatriation Reimbursement Request	Form and Instruction	Modified	Routine Repatriation Reimbursement Request - Spanish
218656	Routine Repatriation Reimbursement Request	Form and Instruction	Modified	Routine Repatriation Reimbursement Request - Simplified Chinese
218656	Routine Repatriation Reimbursement Request	Form and Instruction	Modified	Routine Repatriation Reimbursement Request - Russian
218656	Routine Repatriation Reimbursement Request	Form and Instruction	Modified	Routine Repatriation Reimbursement Request - French
218656	Routine Repatriation Reimbursement Request	Form and Instruction	Modified	Routine Repatriation Reimbursement Request - Arabic
218656	Routine Repatriation Reimbursement Request	Form and Instruction	Modified	Routine Repatriation Reimbursement Request
218656	Routine Repatriation Reimbursement Request	Form and Instruction	Modified
218655	Loan Waiver and Deferral Application	Form and Instruction	Modified	Loan Waiver and Deferral Application - Traditional Chinese
218655	Loan Waiver and Deferral Application	Form and Instruction	Modified	Loan Waiver and Deferral Application - Spanish
218655	Loan Waiver and Deferral Application	Form and Instruction	Modified	Loan Waiver and Deferral Application - Simplified Chinese
218655	Loan Waiver and Deferral Application	Form and Instruction	Modified	Loan Waiver and Deferral Application - Russian
218655	Loan Waiver and Deferral Application	Form and Instruction	Modified	Loan Waiver and Deferral Application - French
218655	Loan Waiver and Deferral Application	Form and Instruction	Modified	Loan Waiver and Deferral Application - Arabic
218655	Loan Waiver and Deferral Application	Form and Instruction	Modified	Loan Waiver and Deferral Application
218655	Loan Waiver and Deferral Application	Form and Instruction	Modified
218654	Emergency Repatriation Reimbursement Request	Form and Instruction	Modified	Emergency Repatriation Reimbursement Request - Traditional Chinese
218654	Emergency Repatriation Reimbursement Request	Form and Instruction	Modified	Emergency Repatriation Reimbursement Request - Spanish
218654	Emergency Repatriation Reimbursement Request	Form and Instruction	Modified	Emergency Repatriation Reimbursement Request - Simplified Chinese
218654	Emergency Repatriation Reimbursement Request	Form and Instruction	Modified	Emergency Repatriation Reimbursement Request - Russian
218654	Emergency Repatriation Reimbursement Request	Form and Instruction	Modified	Emergency Repatriation Reimbursement Request - French
218654	Emergency Repatriation Reimbursement Request	Form and Instruction	Modified	Emergency Repatriation Reimbursement Request - Arabic
218654	Emergency Repatriation Reimbursement Request	Form and Instruction	Modified	Emergency Repatriation Reimbursement Request
218654	Emergency Repatriation Reimbursement Request	Form and Instruction	Modified
218653	Emergency Repatriation Eligibility Application	Form and Instruction	Modified	Emergency Repatriation Eligibility Application - Traditional Chinese
218653	Emergency Repatriation Eligibility Application	Form and Instruction	Modified	Emergency Repatriation Eligibility Application - Spanish
218653	Emergency Repatriation Eligibility Application	Form and Instruction	Modified	Emergency Repatriation Eligibility Application - Simplified Chinese
218653	Emergency Repatriation Eligibility Application	Form and Instruction	Modified	Emergency Repatriation Eligibility Application - Russian
218653	Emergency Repatriation Eligibility Application	Form and Instruction	Modified	Emergency Repatriation Eligibility Application - French
218653	Emergency Repatriation Eligibility Application	Form and Instruction	Modified	Emergency Repatriation Eligibility Application - Arabic
218653	Emergency Repatriation Eligibility Application	Form and Instruction	Modified	Emergency Repatriation Eligibility Application
218653	Emergency Repatriation Eligibility Application	Form and Instruction	Modified

ICR Details

OMB Control No: 0970-0474	ICR Reference No: 202304-0970-011
Status: Historical Active	Previous ICR Reference No: 202204-0970-004
Agency/Subagency: HHS/ACF	Agency Tracking No: OHSEPR
Title: U.S. Repatriation Program Forms
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/03/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/01/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2025	06/30/2025	06/30/2025
Responses	2,535	0	2,535
Time Burden (Hours)	802	0	802
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection allows OHSEPR to fulfill its statutory responsibilities to provide temporary assistance to repatriates. OHSEPR uses this information collection to conduct both emergency and routine repatriation. These forms allow OHSEPR to conduct Program operations regarding: 1) determining a repatriate’s eligibility for temporary assistance 2) granting extensions for temporary assistance beyond the 90-day eligibility period 3) collecting repatriation loans from repatriates and to grant loan waivers and deferrals 4) reimbursing states and service providers for temporary assistance provided to eligible repatriates and 5) pre-approving states’ costs for emergency repatriation. OHSEPR made changes to all eight forms to ensure the information collected aligns with Program statutes and regulations as well as the purpose and use of the form. Revisions include clarifying statutory authority and general instructions on completing and submitting the forms. These changes make the forms more user friendly. OHSEPR also reduced the burden estimates to make them more accurate.

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Authorizing Statute(s): EO: EO 12656 Name/Subject of EO: Assignment of Emergency Preparedness Responsibilities
   US Code: 24 USC 321-329 Name of Law: Hospitals and Asylums
   US Code: 42 USC 1313 Name of Law: Social Security 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 6569	02/04/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 21662	04/12/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Emergency Repatriation Eligibility Application	RR-01, RR-01 , RR-01, RR-01, RR-01, RR-01, RR-01	Emergency Repatriation Eligibility Application ,   Emergency Repatriation Eligibility Application - Arabic ,   Emergency Repatriation Eligibility Application - French ,   Emergency Repatriation Eligibility Application - Russian ,   Emergency Repatriation Eligibility Application - Simplified Chinese ,   Emergency Repatriation Eligibility Application - Spanish ,   Emergency Repatriation Eligibility Application - Traditional Chinese
Emergency Repatriation Reimbursement Request	RR-02, RR-02, RR-02, RR-02, RR-02, RR-02, RR-02	Emergency Repatriation Reimbursement Request ,   Emergency Repatriation Reimbursement Request - Arabic ,   Emergency Repatriation Reimbursement Request - French ,   Emergency Repatriation Reimbursement Request - Russian ,   Emergency Repatriation Reimbursement Request - Simplified Chinese ,   Emergency Repatriation Reimbursement Request - Spanish ,   Emergency Repatriation Reimbursement Request - Traditional Chinese
Emergency Repatriation Request for Cost Approval and Federal Support	RR-08, RR-08, RR-08, RR-08, RR-08, RR-08, RR-08	Emergency Repatriation Request for Cost Approval and Federal Support ,   Emergency Repatriation Request for Cost Approval and Federal Support - Arabic ,   Emergency Repatriation Request for Cost Approval and Federal Support - French ,   Emergency Repatriation Request for Cost Approval and Federal Support - Russian ,   Emergency Repatriation Request for Cost Approval and Federal Support - Simplified Chinese ,   Emergency Repatriation Request for Cost Approval and Federal Support - Spanish ,   Emergency Repatriation Request for Cost Approval and Federal Support - Traditional Chinese
Loan Waiver and Deferral Application	RR-03, RR-03, RR-03, RR-03, RR-03, RR-03, RR-03	Loan Waiver and Deferral Application ,   Loan Waiver and Deferral Application - Arabic ,   Loan Waiver and Deferral Application - French ,   Loan Waiver and Deferral Application - Russian ,   Loan Waiver and Deferral Application - Simplified Chinese ,   Loan Waiver and Deferral Application - Spanish ,   Loan Waiver and Deferral Application - Traditional Chinese
Refusal of Temporary Assistance	RR-06, RR-06, RR-06, RR-06, RR-06, RR-06, RR-06	Refusal of Temporary Assistance ,   Refusal of Temporary Assistance - Arabic ,   Refusal of Temporary Assistance - French ,   Refusal of Temporary Assistance - Russian ,   Refusal of Temporary Assistance - Simplified Chinese ,   Refusal of Temporary Assistance - Spanish ,   Refusal of Temporary Assistance - Traditional Chinese
Repatriation Repayment and Privacy Agreement	RR-05, RR-05, RR-05, RR-05, RR-05, RR-05, RR-05	Repatriation Repayment and Privacy Agreement ,   Repatriation Repayment and Privacy Agreement - Arabic ,   Repatriation Repayment and Privacy Agreement - French ,   Repatriation Repayment and Privacy Agreement - Russian ,   Repatriation Repayment and Privacy Agreement - Simplified Chinese ,   Repatriation Repayment and Privacy Agreement - Spanish ,   Repatriation Repayment and Privacy Agreement - Traditional Chinese
Routine Repatriation Reimbursement Request	RR-04, RR-04, RR-04, RR-04, RR-04, RR-04, RR-04	Routine Repatriation Reimbursement Request ,   Routine Repatriation Reimbursement Request - Arabic ,   Routine Repatriation Reimbursement Request - French ,   Routine Repatriation Reimbursement Request - Russian ,   Routine Repatriation Reimbursement Request - Simplified Chinese ,   Routine Repatriation Reimbursement Request - Spanish ,   Routine Repatriation Reimbursement Request - Traditional Chinese
Temporary Assistance Extension Request	RR-07, RR-07, RR-07, RR-07, RR-07, RR-07, RR-07	Temporary Assistance Extension Request ,   Temporary Assistance Extension Request - Arabic ,   Temporary Assistance Extension Request - French ,   Temporary Assistance Extension Request - Russian ,   Temporary Assistance Extension Request - Simplified Chinese ,   Temporary Assistance Extension Request - Spanish ,   Temporary Assistance Extension Request - Traditional Chinese

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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	2,535	2,535	0	0	0	0
Annual Time Burden (Hours)	802	802	0	0	0	0
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: OHSEPR made changes to all eight forms and adjusted the burden and cost estimates to make them more accurate, based on current numbers and experiences to-date. See section A12 of the Supporting Statement for information about updates to burden estimates. In addition to updates to burden estimates as described in the Supporting Statement, the forms were uploaded in order for this submission and as such, some of the changes to burden on IC lines with ROCIS are due to shifting the order of entries.

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Annual Cost to Federal Government: $188,568

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: 05/01/2023

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