Retaining Employment and Talent after Injury/Illness Network (RETAIN) Demonstration Projects and Evaluation

OMB: 1230-0014

IC ID: 235436

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1230-0014 can be found here:

2022-03-15 - Extension without change of a currently approved collection

Documents and Forms

Document Name Document Type
RETAIN Baseline Participant Form Part 1.docx Other-Survey
RETAIN Baseline Participant Form Part 1.docx Other-Survey
RETAIN Baseline Participant Form Part 2.docx Other-Survey
RETAIN Baseline Participant Form Part 2.docx Other-Survey
RETAIN Baseline Participant Form Part 1_Spanish.docx Other-Survey
RETAIN Baseline Participant Form Part 1_Spanish.docx Other-Survey
RETAIN Baseline Participant Form Part 2_Spanish.docx Other-Survey
RETAIN Baseline Participant Form Part 2_Spanish.docx Other-Survey
RETAIN Baseline Participant Form Part 1, revised for Phase 2.docx Other-Survey
RETAIN Baseline Participant Form Part 1, revised for Phase 2.docx Other-Survey
RETAIN Baseline Participant Form Part 2, revised for Phase 2.docx Other-Survey
RETAIN Baseline Participant Form Part 2, revised for Phase 2.docx Other-Survey
RETAIN Baseline Participant Form Part 1, revised for Phase 2 and Privacy Act Statement.docx Other-Survey
RETAIN Baseline Participant Form Part 1, revised for Phase 2 and Privacy Act Statement.docx Other-Survey
RETAIN SSA Authori RETAIN SSA Authorization of Disclosure Form RETAIN SSA Authorization of Disclosure Form.docx Form and Instruction
RETAIN SSA Authori RETAIN SSA Authorization of Disclosure Form RETAIN SSA Authorization of Disclosure Form.docx Form and Instruction
Spanish version of Spanish version of Disclosure Form Spanish RETAIN SSA Authorization of Disclosure Form FINAL.DOCX Form and Instruction
Spanish version of Spanish version of Disclosure Form Spanish RETAIN SSA Authorization of Disclosure Form FINAL.DOCX Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Retaining Employment and Talent after Injury/Illness Network (RETAIN) Demonstration Projects and Evaluation	Agency IC Tracking Number:	201803-0320-001

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey			RETAIN Baseline Participant Form Part 1.docx	Yes	Yes	Fillable Fileable
Other-Survey			RETAIN Baseline Participant Form Part 2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	RETAIN SSA Authorization of Disclosure Form	RETAIN SSA Authorization of Disclosure Form	RETAIN SSA Authorization of Disclosure Form.docx	Yes	Yes	Fillable Printable
Form and Instruction	Spanish version of Disclosure Form	Spanish version of Disclosure Form	Spanish RETAIN SSA Authorization of Disclosure Form FINAL.DOCX	Yes	Yes	Fillable Printable
Other-Survey			RETAIN Baseline Participant Form Part 1_Spanish.docx	Yes	Yes	Fillable Fileable
Other-Survey			RETAIN Baseline Participant Form Part 2_Spanish.docx	Yes	Yes	Fillable Fileable
Other-Survey			RETAIN Baseline Participant Form Part 1, revised for Phase 2.docx	Yes	Yes	Fillable Fileable
Other-Survey			RETAIN Baseline Participant Form Part 2, revised for Phase 2.docx	Yes	Yes	Fillable Fileable
Other-Survey			RETAIN Baseline Participant Form Part 1, revised for Phase 2 and Privacy Act Statement.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,333	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,333	5,333
Annual IC Time Burden (Hours)	1,778	1,778
Annual IC Cost Burden (Dollars)	146,817	146,817

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.