Free SD Form 455, Request for Approval of Information Collection, April 2006 - Federal

REQUEST FOR APPROVAL OF INFORMATION COLLECTION
(See Instructions on back before completing form.) 1. FROM (Organization name, directorate, and mailing address) 2. DATE OF REQUEST (YYYYMMDD)

3. INFORMATION REQUIREMENT DATA
a. REPORT TITLE b. (X one) NEW d. FREQUENCY e. INITIAL DUE DATE f. RELATED REQUIREMENTS (RCS's) (YYYYMMDD) REVISED g. FORM NO.(S) (If applicable) c. EXISTING REPORT CONTROL SYMBOL (RCS) (If applicable)

DDh. SYSTEM RECORDS i. SURVEY (Y/N)

4. APPLICABLE DOCUMENTS (List number(s) next to type)
(1) PRESCRIBING a. DOD ISSUANCE b. STATUTORY c. INTERAGENCY d. OTHER (e.g. Memo) e. FORMS (2) REPLACED

5. ESTIMATED COST OF REQUIREMENT
a. RESPONDENT NAME ANNUAL RECURRING COST b. c. d. e. INITIAL NUMBER COST COST ONE-TIME REPORTS PER PER COST IN YEAR REPORT YEAR f. TOTAL ESTIMATED COST

Total Costs

$0

0

$0

0 0 0 0 0 0 $0

$0 $0 $0 $0 $0 $0 $0

6. JUSTIFICATION OF SPECIFIC NEED FOR THIS INFORMATION REQUIREMENT

7. COORDINATION (Do not complete if this information collection is
contained in an approved DoD issuance.) a. NAME b. ORGANIZATION c. TELEPHONE NO.

8. PROJECT OFFICER
a. TYPED NAME b. SIGNATURE c. TELEPHONE NO.

9. REQUESTING ORGANIZATION APPROVING OFFICIAL
a. TYPED NAME c. SIGNATURE b. TITLE

10. INFORMATION MANAGEMENT CONTROL OFFICER (IMCO)
a. TYPED NAME b. SIGNATURE

11. FOR USE OF WHS/ESD (INFORMATION MANAGEMENT DIVISION)
a. REPORT CONTROL SYMBOL (RCS) b. EXPIRATION DATE (YYYYMMDD) c. SIGNATURE d. DATE SIGNED (YYYYMMDD)

DDSD FORM 455, APR 2006
PREVIOUS EDITION IS OBSOLETE.

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INSTRUCTIONS FOR COMPLETION OF SD FORM 455, "REQUEST FOR APPROVAL OF INFORMATION COLLECTION"
General - DoD Directive 8910.1 (See Note 1) prescribes the policy and DoD 8910.1-M (See Note 2) prescribes the procedures which implement the policy for the management and control of DoD internal information requirements. WHS/ESD (Information Management Division (IMD)) maintains an inventory of all approved OSD information requirements. SD Form 455, "Request for Approval of Information Collection," is used to request approval of new or revised information requirements, other than public or interagency information requirements. Coordination Procedure - The originating organization's project officer must coordinate this request with that organization's approving official and Information Management Control Officer (IMCO) (See Item 10, Note 3). The IMCO must review and coordinate on this request prior to submission to WHS/ESD/IMD. When approved, it will be returned to the IMCO for distribution. Copies - Submit one original copy. Item 1 - Provide organization originating the request, including the directorate or equivalent level. Item 3a - Provide exact title of report, information system, recordkeeping requirement, data base, etc., as it appears in prescribing issuance or memorandum. Item 3c - If this is a revision, provide the existing Report Control Symbol (RCS). Item 3d - Provide the reporting frequency. A AR BI BM BW = Annually = As Required = Biennially = Bimonthly = Biweekly D M OT QD Q = Daily = Monthly = One Time = Quadrennially = Quarterly QI SA TRA TRI W = Quintennially = Semiannually = Thrice Yearly = Triennially = Weekly Item 4a, b, c, d, e (2) - Cite all existing DoD directives, instructions, manuals, memoranda, forms, etc., or non-DoD requirements, to be superseded by this requirement. Item 5a - Army, Navy, Air Force, DLA, etc. Item 5b - Provide set-up costs to include cost of personnel, ADP machine time, if applicable, supplies, etc. Item 5c, d, e - Provide cost of each report, to include personnel cost (number of work-hours X average cost per work-hour), ADP machine time, if applicable, supplies used, etc. Multiply cost per report times the number of reports in a year to arrive at total cost per year. Item 5f - Sum of initial one-time cost and annual recurring cost (total of 5b and e). Item 6 - Provide a concise but complete justification for the requirement. Include an explanation or discussion of: (a) specific need for requirement and resulting benefits in light of projected costs; (b) risks or penalties associated with not having the information; (c) the results of examining other sources of information currently available and why such information cannot satisfy the requirement; (d) less costly alternatives considered for satisfying the requirement and why each was not chosen; (e) how it is to be used by recipients; and (f) how need and use warrant frequency requested. Use a continuation sheet, if necessary. Item 7 - Do not complete this item when DoD-wide concurrence is obtained through a DoD issuance coordination process. However, a statement must be made that concurrence was obtained by this method. This block must be completed when any other coordination process is used, such as letter or memorandum. The originator of the information collection will provide the name, organization, and telephone number of each component or organization responsible for providing the information (signature or initials are not required). Where concurrence cannot be obtained, the originator will provide a statement of the reasons why concurrence was not obtained and attach it to this form. If a Privacy Act Statement is required, coordinate with your Privacy Program official (See Note 3). Item 8 - Provide typed name, phone number and signature of project officer. Item 9 - Provide typed name, title, and signature of the head or principal deputy of the requesting organization. Item 10 - The Information Management Control Officer (IMCO) designated for the originating activity indicates coordination by signing this block. Item 11 - This block is only for use of WHS/ESD/IMD, who will assign an expiration date for each RCS not to exceed three years. All internal information reporting requirements are reviewed at a minimum every three years to assess improvements, cancellations and extensions (See Note 2).

Item 3e - Provide the initial report due date. Item 3f - Cite references of existing related Report Control Symbols. Item 3g - If forms are used in this reporting requirement, provide the form numbers. Item 3h - If the information requested has a Privacy Act Statement (PAS), provide the System of Records Number (See Note 3). Item 3i - Indicate whether this collection is a survey. If it is an attitude/opinion survey, obtain Defense Manpower Data Center (DMDC) coordination in Item 7a or attach DMDC review comments to the SD455 and submit to WHS/ESD/IMD. Item 4a(1) - For internal DoD requirements, cite the proposed or existing DoD directive, instruction, manual or memorandum. Item 4b(1) - If this requirement is prescribed by Federal statute, cite the statute - e.g., Section xxx, PL xxx-xxx. Item 4c(1) - If this requirement originates in another Federal government agency, provide agency and prescribing regulation, directive, etc. - e.g., Treasury Department Regulation xxx. Item 4d(1) - Cite any other non-DoD source, such as Congressional requests not incorporated in Federal statutes, requests from State governments, etc.

NOTES 1. DoDD 8910.1, Management and Control of Information Requirements 2. DoD 8910.1-M, DoD Procedures for Management of Information Requirements 3. DoD 5400.11-R, Department of Defense Privacy Program

SD FORM 455 (BACK), APR 2006