OMB control number

DOI Access & Consent Forms

OMB 1093-0013 · DOI/OS.

OMB 1093-0013

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.

The latest form for DOI Access & Consent Forms expires 2026-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form DI-4017 CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PRIVACY ACT Form and Instruction
Form DI-4016 REQUEST FOR INDIVIDUAL ACCESS TO RECORDS PROTECTED UNDER THE PRIVACY ACT Form and Instruction
1093-0013 Published 30 Day Notice - 91 FR 718 - 01082026.pdf Supplementary Document
1093-0013 - Supporting Statement A (508)_Access and Consent Forms 12182025.docx Supporting Statement A
1093-0013 Published 60 Day Notice - 90 FR 17950 - 04302025.pdf Supplementary Document
SORN - FWS 5.pdf Supplementary Document
M-21-04.pdf Supplementary Document
PLAW-116publ50.pdf Supplementary Document
DI-4017, Consent for Disclosure of Records Protected under the Privacy Act Form and Instruction
DI-4016, Request for Individual Access to Records Protected under the Privacy Act, Form and Instruction

All Historical Document Collections

202504-1093-001	Extension without change of a currently approved collection	2026-01-08
202210-1093-001 Approved with change	Existing collection in use without an OMB Control Number	2022-10-21

OMB Details

DI-4016, Request for Individual Access to Records Protected under the Privacy Act,

Federal Enterprise Architecture: General Government - Central Records & Statistical Mgt

Form DI-4016

REQUEST FOR INDIVIDUAL ACCESS TO RECORDS PROTECTED UNDER THE PRIVACY ACT

Fillable Fileable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.