Contractor Information Worksheet; GSA Form 850

Forms and Documents

Document Name	Status
Form GSA 850 Contractor Information Worksheet, GSA Form 850 Form and Instruction	Modified
3090-0283-Supporting Statement.doc Supporting Statement A	2019-07-24

IC Document Collections

IC ID	Document Title	Status
188501	Contractor Information Worksheet, GSA Form 850 Form and Instruction	Modified

ICR Details

OMB Control No: 3090-0283	ICR Reference No: 201907-3090-003
Status: Active	Previous ICR Reference No: 201611-3090-003
Agency/Subagency: GSA	Agency Tracking No:
Title: Contractor Information Worksheet; GSA Form 850
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/22/2019
	Date Received in OIRA: 07/02/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2022	36 Months From Approved	09/30/2019
Responses	25,000	0	25,000
Time Burden (Hours)	6,250	0	6,250
Cost Burden (Dollars)	248,625	0	248,625

---

Abstract: GSA requires the collection of the information in the Contractor Information Worksheet to authorize and initiate background check requests for GSA contractors and to obtain a GSA Access Card. The background checks are carried out by the Office of Personnel Management, Facilities, Security & Contracting-Personnel Security (OPM FSC) and the credentialing process is carried out by the GSA’s Managed Service Office (MSO) in accordance with the terms and conditions of separate Memoranda of Agreement (MOAs).

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 11418	04/09/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 31593	07/02/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Contractor Information Worksheet, GSA Form 850	GSA 850	Contractor Information Worksheet

---

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	25,000	25,000	0	0	0	0
Annual Time Burden (Hours)	6,250	6,250	0	0	0	0
Annual Cost Burden (Dollars)	248,625	248,625	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:

---

Annual Cost to Federal Government: $137,480

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

---

Common Form ICR:  No

---

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: 07/02/2019

---