E-Appeal/US Merit Systems Protection Board Appeal Form

Forms and Documents

Document Name	Status
Justification for No Material-Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change	2017-07-26
PRA Final Supporting Statement A - MSPB Appeal Form 185 3-29-2013.pdf Supporting Statement A	2013-04-03

IC Document Collections

IC ID	Document Title	Status

ICR Details

OMB Control No: 3124-0009	ICR Reference No: 201707-3124-001
Status: Historical Active	Previous ICR Reference No: 201606-3124-001
Agency/Subagency: MSPB	Agency Tracking No:
Title: E-Appeal/US Merit Systems Protection Board Appeal Form
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/08/2017
	Date Received in OIRA: 07/26/2017
Terms of Clearance: Giving MSPB an additional year to make planned changes to the form and to update applicable Privacy Act notices.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2018	36 Months From Approved
Responses	7,150	0	0
Time Burden (Hours)	7,150	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This is a voluntary form completed by persons who file appeals with the U.S. Merit Systems Protection Board. The form serves as a guide to appellants in providing all needed information. It is available both as a static form, which is available upon request, on our website (http://www.mspb.gov/appeals/revisedappealform.htm).

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Authorizing Statute(s): US Code: 5 USC 1204, 1221, 3330a, 7701 Name of Law: Civil Service Reform Act and others
  

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:
	77 FR 71640	12/03/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 20142	04/03/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 0

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ICR Summary 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	7,150	0	0	0	0	7,150
Annual Time Burden (Hours)	7,150	0	0	0	0	7,150
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: $0

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.     Yes

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.     Yes

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? Uncollected

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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: 07/26/2017

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