Information Collection

Report of Public Safety Officers' Permanent and Total Disability

IC 12434 under ICR 201605-1121-002 · OMB 1121-0166.

Documents and Forms

Document Name Document Type
Form OJP form 3650/7 Report of Public Safety Officers' Permanent and Total Disability Form
OJP form 3650/7 Report of Public Safety Officers Permanent and Total Dis disability_claim.pdf www.psob.gov Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Report of Public Safety Officers' Permanent and Total Disability	Agency IC Tracking Number:	BJA

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	OJP form 3650/7	Report of Public Safety Officers Permanent and Total Disability	disability_claim.pdf	www.psob.gov	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	75	-25	100
Annual IC Time Burden (Hours)	188	-12	200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.