Request for Assistance from the Department of Labor, Employee Benefits Security Administration

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 301 Request for Assistance from Department of Labor, EBSA (English Web Option Screenshots)	Form and Instruction	Modified	Available
Form 301 Request for Assistance from Department of Labor, EBSA (English Paper Version)	Form and Instruction	Modified	Available
Form 301 Customer Service Intake Form	Form and Instruction	Modified	Repair queued
1210-0146 Supporting Statement Web Intake Form 02-09-24 (3).docx	Supporting Statement A	Uploaded 2025-08-29	Available
1210-0146 Supporting Statement Web Intake Form 02-09-24 (3).docx	Supporting Statement A	Uploaded 2025-08-29	Repair queued
1210-0146 Justification for No material or Non-substantive Change to Currently Approved Collection 8.29.2025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-08-29	Available
1210-0146 Justification for No material or Non-substantive Change to Currently Approved Collection 8.29.2025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-08-29	Repair queued
29 U.S. Code § 1134 - Investigative authority.pdf	Supplementary Document	Uploaded 2021-01-07	Available
29 U.S. Code § 1134 - Investigative authority.pdf	Supplementary Document	Uploaded 2021-01-07	Repair queued
29 U.S. Code § 1143 - Research, studies, and reports _ U.S. Code _ US Law _ LII _ Legal Information Institute.pdf	Supplementary Document	Uploaded 2021-01-07	Available
29 U.S. Code § 1143 - Research, studies, and reports _ U.S. Code _ US Law _ LII _ Legal Information Institute.pdf	Supplementary Document	Uploaded 2021-01-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198333	Customer Service Intake Form	Form and Instruction	Modified	Request for Assistance from Department of Labor, EBSA (English Web Option Screenshots)
198333	Customer Service Intake Form	Other-Web Screenshots of Privacy Act and PRA Notices (English)	Modified
198333	Customer Service Intake Form	Form and Instruction	Modified	Request for Assistance from Department of Labor, EBSA (English Paper Version)
198333	Customer Service Intake Form	Form and Instruction	Modified

ICR Details

OMB Control No: 1210-0146	ICR Reference No: 202508-1210-010
Status: Active	Previous ICR Reference No: 202409-1210-003
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Request for Assistance from the Department of Labor, Employee Benefits Security Administration
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: 09/08/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/29/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2027	04/30/2027	04/30/2027
Responses	14,991	0	14,991
Time Burden (Hours)	7,496	0	7,496
Cost Burden (Dollars)	0	0	0

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Abstract: The Department of Labor's Employee Benefits Security Administration (EBSA) maintains a program designed to provide education and technical assistance to participants and beneficiaries as well as to employers, plan sponsors, and service providers related to their health and retirement plan benefits. EBSA assists participants in understanding their rights, responsibilities, and benefits under employee benefit law and intervenes informally on their behalf with the plan sponsor in order to assist them in obtaining the health and retirement benefits to which they may have been inappropriately denied, which can avert the necessity for a formal investigation or a civil action. EBSA maintains a toll-free telephone number through which inquirers can reach Benefits Advisors in ten Regional Offices. EBSA has also made a request for assistance form available on its website for those wishing to obtain assistance in this manner. Contact with EBSA is entirely voluntary. The collection of information is an intake form for assistance requests from the public. This information includes the plan type, broad categories of problem type, contact information for responsible parties, and a mechanism for the inquirer to attach relevant documents. Summary data from the existing intake form has also been used, in accordance with section 513 of ERISA, to respond to requests for information regarding employee benefit plans from members of Congress and governmental oversight entities, and to inform the policy formulation process.

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Authorizing Statute(s): US Code: 29 USC 1134 Name of Law: ERISA Section 504
   US Code: 29 USC 1143 Name of Law: ERISA Section 513
  

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 58312	08/25/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 13750	02/23/2024
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
Customer Service Intake Form	301, 301	Request for Assistance from Department of Labor, EBSA (English Paper Version) ,   Request for Assistance from Department of Labor, EBSA (English Web Option Screenshots)

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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	14,991	14,991	0	0	0	0
Annual Time Burden (Hours)	7,496	7,496	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: $1,500

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.     No

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: 08/29/2025

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