Information Collection

Customer Service Intake Form

IC 198333 under ICR 202409-1210-003 · OMB 1210-0146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0146 can be found here:

2025-08-29 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 301 Customer Service Intake Form	Form and Instruction
Request for Assistance Privacy Act and PRA Notices Screenshots (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx	Other-Web Screenshots of Privacy Act
Request for Assistance Privacy Act and PRA Notices Screenshots (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx	Other-Web Screenshots of Privacy Act
Request for Assistance Privacy Act and PRA Notices Screenshots (Spanish).pdf www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Other-Web Screenshots of Privacy Act
Request for Assistance Privacy Act and PRA Notices Screenshots (Spanish).pdf www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Other-Web Screenshots of Privacy Act
301 Request for Assistance from Department of Labor, EBSA (E Request for Assistance Paper Option (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx	Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (E Request for Assistance Paper Option (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx	Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (S Request for Assistance Paper Option (Spanish).pdf www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (S Request for Assistance Paper Option (Spanish).pdf www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (E Request for Assistance Web Option Screenshots (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx	Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (E Request for Assistance Web Option Screenshots (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx	Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (S Request for Assistance Web Option Screenshots (Spanish).pdf www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (S Request for Assistance Web Option Screenshots (Spanish).pdf www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Customer Service Intake Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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 and Instruction	301	Request for Assistance from Department of Labor, EBSA (English Paper Version)	Request for Assistance Paper Option (English).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx	Yes	Yes	Fillable Fileable
Form and Instruction	301	Request for Assistance from Department of Labor, EBSA (Spanish Paper Version)	Request for Assistance Paper Option (Spanish).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Yes	Yes	Fillable Fileable
Other-Web Screenshots of Privacy Act and PRA Notices (English)			Request for Assistance Privacy Act and PRA Notices Screenshots (English).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx	Yes	Yes	Fillable Fileable
Other-Web Screenshots of Privacy Act and PRA Notices (Spanish)			Request for Assistance Privacy Act and PRA Notices Screenshots (Spanish).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Yes	Yes	Fillable Fileable
Form and Instruction	301	Request for Assistance from Department of Labor, EBSA (English Web Option Screenshots)	Request for Assistance Web Option Screenshots (English).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx	Yes	Yes	Fillable Fileable
Form and Instruction	301	Request for Assistance from Department of Labor, EBSA (Spanish Web Option Screenshots)	Request for Assistance Web Option Screenshots (Spanish).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx?l=es	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: Technical Assistance and Inquiry Files, DOL/PWBAÂ4

FR Citation: 67 FR 16816

Number of Respondents: 14,991

Number of Respondents for Small Entity: 11,573

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	14,991	14,991
Annual IC Time Burden (Hours)	7,496	7,496
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.