Personnel Accountability & Assessment Notification for COVID-19

Forms and Documents

Document Name	Status
Form DD Form 3112 Personnel Accountability & Assessment Notification for COVID-19 Form	New
0720-CVID_SSA_4.3.2020 LP.docx Supporting Statement A	2020-04-03

IC Document Collections

IC ID	Document Title	Status
241131	Personnel Accountability & Assessment Notification for COVID-19 Form	New

ICR Details

OMB Control No: 0704-0590	ICR Reference No: 202004-0704-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOD/DODDEP	Agency Tracking No:
Title: Personnel Accountability & Assessment Notification for COVID-19
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 04/03/2020
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/03/2020
	Date Received in OIRA: 04/03/2020
Terms of Clearance: This collection is approved for 6 months only. Should the Department want to use it for a longer time period, DOD must publish a 60 and 30 notice for public comment in the Federal Register.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	6 Months From Approved
Responses	100,000	0	0
Time Burden (Hours)	8,333	0	0
Cost Burden (Dollars)	60,000	0	0

---

Abstract: The principal purpose of the DD form 3112, “Personnel Accountability and Assessment Notification for a Public Health Emergency,” is to collect information used to protect the health and safety of individuals working in, residing on, or assigned to DoD installations, facilities, field operations, and commands, and to protect the DoD mission.

Emergency Justfication: In light of the current COVID-19 pandemic, the DoD has identified the need to collect and standardize information from members of the public who have been potentially exposed to COVID-19. There is an immediate need to collect this information to protect the health and safety of individuals working in, residing on, or assigned to DoD installations, facilities, field operations, and commands.

---

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

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
Personnel Accountability & Assessment Notification for COVID-19	DD Form 3112	Personnel Accountability & Assessment Notification for COVID-19

---

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	100,000	0	0	100,000	0	0
Annual Time Burden (Hours)	8,333	0	0	8,333	0	0
Annual Cost Burden (Dollars)	60,000	0	0	60,000	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

---

Annual Cost to Federal Government: $1,020,500

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? Yes

---

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: 04/03/2020

---