USDA PIV Request for Credential

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0505-0022 can be found here:

Documents and Forms

Document Name Document Type
Form AD-1197 USDA PIV Request for Credential Form
AD-1197 Request for USDA Identification (ID) Badge ad1197.pdf Form
DM4620-002.pdf DM 4620-0002 IC Document
DR4620-002.pdf DR 4620-002 IC Document
Sponsor Quick Reference Guide March 2016.pdf Sponsor Quick Reference GUIDE IC Document
Person_Model_Fields 11.22.16.pdf Person Model Sponsor and Date Entry Training IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	USDA PIV Request for Credential	Agency IC Tracking Number:

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	AD-1197	Request for USDA Identification (ID) Badge	ad1197.pdf		Yes	No	Fillable Printable

Line of Business: Homeland Security

Subfunction: Key Asset and Critical Infrastructure Protection

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Previously Approved
Annual Number of Responses for this IC	12,000	12,000
Annual IC Time Burden (Hours)	30,000	30,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
DM 4620-0002	DM4620-002.pdf	06/29/2009
DR 4620-002	DR4620-002.pdf	06/29/2009
Sponsor Quick Reference GUIDE	Sponsor Quick Reference Guide March 2016.pdf	02/13/2017
Person Model Sponsor and Date Entry Training	Person_Model_Fields 11.22.16.pdf	02/13/2017

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