DOI Access & Consent Forms

Forms and Documents

Document Name	Status
Form DI-4017 DI-4017, Consent for Disclosure of Records Protected under the Privacy Act Form and Instruction	Unchanged
Form DI-4016 DI-4016, Request for Individual Access to Records Protected under the Privacy Act, Form and Instruction	Unchanged
1093-0013 Published 30 Day Notice - 91 FR 718 - 01082026.pdf Supplementary Document	2026-01-08
1093-0013 - Supporting Statement A (508)_Access and Consent Forms 12182025.docx Supporting Statement A	2025-12-18
1093-0013 Published 60 Day Notice - 90 FR 17950 - 04302025.pdf Supplementary Document	2025-04-30
SORN - FWS 5.pdf Supplementary Document	2022-10-21
M-21-04.pdf Supplementary Document	2022-10-21
PLAW-116publ50.pdf Supplementary Document	2022-10-21

IC Document Collections

IC ID	Document Title	Status
256548	DI-4017, Consent for Disclosure of Records Protected under the Privacy Act Form and Instruction	Unchanged
256546	DI-4016, Request for Individual Access to Records Protected under the Privacy Act, Form and Instruction	Unchanged

ICR Details

OMB Control No: 1093-0013	ICR Reference No: 202504-1093-001
Status: Received in OIRA	Previous ICR Reference No: 202210-1093-001
Agency/Subagency: DOI/OS	Agency Tracking No:
Title: DOI Access & Consent Forms
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/08/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2026
Responses	1,325	1,325
Time Burden (Hours)	332	332
Cost Burden (Dollars)	0	0

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Abstract: The Department of the Interior (DOI) developed the DI-4016, Request for Individual Access to Records Protected under the Privacy Act, and DI-4017, Consent for Disclosure of Records Protected under the Privacy Act, forms for individuals to submit requests for accessing, and consenting to the disclosure of, records protected under the Privacy Act of 1974, as amended, 5 U.S.C. 552a. The DI-4016, Request for Individual Access to Records Protected under the Privacy Act, form is used by individuals seeking access to their records and any information pertaining to them that are maintained in DOI’s systems of records. The DI-4017, Consent for Disclosure of Records Protected under the Privacy Act, form provides written consent of the individual to whom the record pertains when disclosing records to another person or an agency. The Privacy Act provides that "the parent of any minor, or the legal guardian of any individual who has been declared to be incompetent due to physical or mental incapacity or age by a court of competent jurisdiction, may act on behalf of the individual.” Therefore, these forms may also be used by a parent or legal guardian. These forms were based on the templates provided in the OMB Memorandum M-21-04, Modernizing Access to and Consent for Disclosure of Records Subject to the Privacy Act, issued on November 12, 2020, which implements the requirements of the Creating Advanced Streamlined Electronic Services for Constituents Act of 2019 (“CASES Act”). The CASES Act was issued in an effort to modernize the Privacy Act request process by requiring agencies to accept access and consent forms from individuals properly identity-proofed and authenticated remotely through a digital service option in addition to an agency’s existing process. The CASES Act also requires the forms to be posted on the agency website's privacy program page and the website updated to include instructions on how individuals may submit requests digitally.

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Authorizing Statute(s): PL: Pub.L. 116 - 50 3 Name of Law: Creating Advanced Streamlined Electronic Services for Constituents Act of 2019 (CASES 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:
	90 FR 17950	04/30/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 718	01/08/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
DI-4016, Request for Individual Access to Records Protected under the Privacy Act,	DI-4016	REQUEST FOR INDIVIDUAL ACCESS TO RECORDS PROTECTED UNDER THE PRIVACY ACT
DI-4017, Consent for Disclosure of Records Protected under the Privacy Act	DI-4017	CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PRIVACY ACT

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ICR Summary of Burden

	Total Request	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	1,325	1,325	0	0	0	0
Annual Time Burden (Hours)	332	332	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: $564,450

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: 01/08/2026

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