Job Corps Health Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form ETA 653 Job Corps Health Questionnaire	Form and Instruction	Modified	Available
Form ETA 653 Job Corps Health Questionnaire	Form and Instruction	Modified	Missing upstream
EO 14168_Non Substantiative_1205-0033_ETA 653 Health Questionnaire.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-13	Repair queued
EO 14168_Non Substantiative_1205-0033_ETA 653 Health Questionnaire.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-13	Repair queued
Appendix 601 Student Rights to Privacy and Disclosure of Information.pdf	Supplementary Document	Uploaded 2023-11-29	Repair queued
Appendix 601 Student Rights to Privacy and Disclosure of Information.pdf	Supplementary Document	Uploaded 2023-11-29	Repair queued
Job Corps Appendix 601 - Student Rights to Privacy and Disclosure of Information.pdf	Supplementary Document	Uploaded 2017-03-10	Repair queued
Job Corps Appendix 601 - Student Rights to Privacy and Disclosure of Information.pdf	Supplementary Document	Uploaded 2017-03-10	Repair queued
1205-0033 Supporting Statement - 11.29.2023_CLEAN.docx	Supporting Statement A	Uploaded 2023-11-29	Repair queued
1205-0033 Supporting Statement - 11.29.2023_CLEAN.docx	Supporting Statement A	Uploaded 2023-11-29	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
12954	Job Corps Health Questionnaire	Form and Instruction	Modified	Job Corps Health Questionnaire
12954	Job Corps Health Questionnaire	Form and Instruction	Modified

ICR Details

OMB Control No: 1205-0033	ICR Reference No: 202503-1205-004
Status: Active	Previous ICR Reference No: 202305-1205-001
Agency/Subagency: DOL/ETA	Agency Tracking No:
Title: Job Corps Health Questionnaire
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: 12/23/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/09/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2026	12/31/2026	12/31/2026
Responses	66,630	0	66,630
Time Burden (Hours)	16,658	0	16,658
Cost Burden (Dollars)	0	0	0

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Abstract: Information on the health status of an applicant to Job Corps is obtained when the applicant completes ETA 653 during an interview with the admissions counselor as part of the admissions process.

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Authorizing Statute(s): US Code: 29 USC 3194-3195 Name of Law: Workforce Innovation and Opportunity 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:
	88 FR 8477	02/09/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 32249	05/19/2023
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
Job Corps Health Questionnaire	ETA 653	Job Corps Health Questionnaire

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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	66,630	66,630	0	0	0	0
Annual Time Burden (Hours)	16,658	16,658	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:

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Annual Cost to Federal Government: $486,464

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.     No

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: 04/09/2025

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