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Federal forms, ICRs, and supporting documents

Information Collection Request

Report of Public Safety Officers' Permanent and Total Disability

ICR 201605-1121-002 · OMB 1121-0166 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form OJP form 3650/7 Report of Public Safety Officers' Permanent and Total Disability Form Modified Repair queued
PSOB DISABILITY JUSTIFICATION 2006 REVISED.doc Supporting Statement A Uploaded 2016-05-12 Available
IC Document Collections
IC IDCollectionTypeStatusForm
12434 Report of Public Safety Officers' Permanent and Total Disability Form Modified
ICR Details
1121-0166 201605-1121-002
Historical Active 201004-1121-002
DOJ/OJP BJA
Report of Public Safety Officers' Permanent and Total Disability
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 07/27/2016
Retrieve Notice of Action (NOA) 05/17/2016
  Inventory as of this Action Requested Previously Approved
07/31/2019 36 Months From Approved
75 0 0
188 0 0
0 0 0
The information collected is pursuant to the Public Safety Officers' Benefit Act of 1976 to determine the eligibility of permanently and totally disabled public safety officers for the payment of benefits. The form includes information necessary to determine that the circumstances that lead to the disability meet the requirements prescribed in 42 U.S.C. Sec. 3796.
US Code: 42 USC 3796 Section 1201 Name of Law: Public Safety Officers¿ Benefits Act of 1976
  
None
Not associated with rulemaking
  81 FR 1224 01/11/2016
81 FR 19240 04/04/2016
No
1
IC Title Form No. Form Name
Report of Public Safety Officers' Permanent and Total Disability OJP form 3650/7 Report of Public Safety Officers Permanent and Total Disability
  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 75 0 0 -25 0 100
Annual Time Burden (Hours) 188 0 0 -12 0 200
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
The number of respondents decreased slightly.
$9,639
No
No
No
No
No
Uncollected
Hope Janke 202 514-6278 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/17/2016