Information Collection

Customer Service Intake Form

IC 198333 under ICR 202508-1210-010 · OMB 1210-0146.

Documents and Forms

Document Name Document Type
Form 301 Customer Service Intake Form Form and Instruction
Form 301 Request for Assistance from Department of Labor, EBSA (English Paper Version) Customer Service Intake Form Form and Instruction
Form 301 Request for Assistance from Department of Labor, EBSA (English Web Option Screenshots) Customer Service Intake Form Form and Instruction
Request for Assistance Privacy Act and PRA Notices Screenshots..pdf www.askebsa.dol.gov/WebIntake/Home.aspx/Notices#privacyInfo Other-Web Screenshots of Privacy Act
Request for Assistance Privacy Act and PRA Notices Screenshots..pdf www.askebsa.dol.gov/WebIntake/Home.aspx/Notices#privacyInfo Other-Web Screenshots of Privacy Act
301 Request for Assistance from Department of Labor, EBSA (E Request for Assistance Paper Option (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (E Request for Assistance Paper Option (English).pdf www.askebsa.dol.gov/WebIntake/Home.aspx Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (E Request for Assistance Web Option Screenshots (English).docx www.askebsa.dol.gov/WebIntake/Home.aspx Form and Instruction
301 Request for Assistance from Department of Labor, EBSA (E Request for Assistance Web Option Screenshots (English).docx www.askebsa.dol.gov/WebIntake/Home.aspx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Customer Service Intake Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	301	Request for Assistance from Department of Labor, EBSA (English Paper Version)	Request for Assistance Paper Option (English).pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx	Yes	Yes	Fillable Fileable
Other-Web Screenshots of Privacy Act and PRA Notices (English)			Request for Assistance Privacy Act and PRA Notices Screenshots..pdf	https://www.askebsa.dol.gov/WebIntake/Home.aspx/Notices#privacyInfo	Yes	Yes	Fillable Fileable
Form and Instruction	301	Request for Assistance from Department of Labor, EBSA (English Web Option Screenshots)	Request for Assistance Web Option Screenshots (English).docx	https://www.askebsa.dol.gov/WebIntake/Home.aspx	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: Technical Assistance and Inquiry Files, DOL/PWBAÂ4	FR Citation: 67 FR 16816

Number of Respondents: 14,991	Number of Respondents for Small Entity: 11,573

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	14,991	14,991
Annual IC Time Burden (Hours)	7,496	7,496
Annual IC Cost Burden (Dollars)	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.

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