Web-based Customer Service Intake Form

Request for Assistance From Department of Labor, EBSA

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0146 can be found here:

Documents and Forms

Document Name Document Type
Form 301 Web-based Customer Service Intake Form Form and Instruction
301 Request for Assistance From Department of Labor, EBSA PROPOSED WEB INTAKE FORM clearance 6 29 11.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Web-based Customer Service Intake Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	301	Request for Assistance From Department of Labor, EBSA	PROPOSED WEB INTAKE FORM clearance 6 29 11.pdf		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/PWBA4	FR Citation: 67 FR 16816

Number of Respondents: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 85 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	15,000	15,000
Annual IC Cost Burden (Dollars)	3,100	3,100

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.