DD Form 2936 Request for Approval of DoD Internal Information Collection

DD Form 2936 or the "Request For Approval Of Dod Internal Information Collection" is a Department of Defense-issued form used by and within the United States Army.

The form - often mistakenly referred to as the DA form 2936 - was last revised on April 1, 2014. Download an up-to-date fillable PDF version of the DD 2936 down below or find it on the Department of Defense documentation website.

ADVERTISEMENT
REQUEST FOR APPROVAL OF DoD INTERNAL INFORMATION COLLECTION
(Read DoD Manual 8910.01 Volume 1, "DoD Information Collections Manual: Procedures for DoD Internal Information Collections" before
completing this form.
Visit the DoD Internal Information Collections Website at http://www.dtic.mil/whs/directives/corres/intinfocollections/iic_home.html
for more information on the DoD internal information collections approval process.)
3. TYPE OF REQUEST
1. CLASSIFICATION OF INFORMATION COLLECTION
2. DATE OF REQUEST
(Select one)
(MM/DD/YYYY)
Secret
Unclassified
Top Secret
Confidential
New
Reinstatement
Revision
Extension
4. PRESCRIBING DOCUMENTS
a. DoD ISSUANCE
b. STATUTE OR LAW
c. INTERAGENCY DOCUMENT
d. OTHER DOCUMENTS
This request will be coordinated
with this issuance.
5. INFORMATION COLLECTION DATA
b. EXISTING RCS/OMB CONTROL NUMBER (If applicable)
a. TITLE OF INFORMATION COLLECTION
c. FREQUENCY OF COLLECTION (Select all that apply)
Annually
As Required
Daily
Monthly
One Time
Quarterly
Specify Other
d. RELATED INFORMATION COLLECTION(S)
e. FORM NUMBER(S)
f. TYPE OF COLLECTION INSTRUMENT(S)
(If applicable)
(If applicable)
(Select all that apply and attach a copy of the collection instrument)
Form
Report
Survey
Website
Information System
Focus Group Protocol
Specify Other
6. JUSTIFICATION STATEMENT
Select One:
(Attach as part of the action package)
7. REQUESTING COMPONENT ORGANIZATION NAME AND DIRECTORATE
8. ACTION OFFICER CONTACT INFORMATION
9. REQUESTING COMPONENT OFFICIAL
a. TYPED NAME
a. TYPED NAME
b. OFFICIAL TITLE
b. OFFICIAL TITLE
c. EMAIL ADDRESS
c. SIGNATURE
d. DATE SIGNED
10. ESTIMATED COST OF INFORMATION COLLECTION
a. REFERENCE ID NUMBER
b. FISCAL YEAR
c. TOTAL COST TO REQUESTER
d. TOTAL COST TO RESPONDENT(S)
e. TOTAL COST OF COLLECTION
11. COORDINATION
(1) APPLICABLE?
(2) SIGNATURE
(3) DATE SIGNED
(Yes/No)
Select One:
a. FORMS MANAGER (Forms)
b. OUSD(P&R)/DIRECTOR, DMDC (Surveys)
Select One:
c. HRPP OFFICIAL (Focus groups and research)
Select One:
Yes/Attached
d. PRIVACY OFFICIAL (All collections)
e. RECORDS MANAGER (All collections)
Select One:
Select One:
f. CIO (Electronic format or systems)
12. RESPONDENT(S) COORDINATION (See page 2 of this form)
13. DoD COMPONENT INFORMATION MANAGEMENT CONTROL OFFICER (IMCO)
a. IMCO TYPED NAME
b. IMCO SIGNATURE
c. DATE SIGNED
d. EMERGENCY APPROVAL REQUESTED
Emergency Approval Request
14. FOR USE BY DoD INTERNAL INFORMATION COLLECTIONS OFFICER ONLY
a. RCS
b. OMB CONTROL NUMBER c. EXPIRATION TYPE
d. IICO SIGNATURE
e. DATE SIGNED (MM/DD/YYYY)
DD-
Expiration Date (MM/DD/YYYY)
DD FORM 2936, APR 2014
PREVIOUS EDITION IS OBSOLETE.
Adobe Designer 9.0
REQUEST FOR APPROVAL OF DoD INTERNAL INFORMATION COLLECTION
(Read DoD Manual 8910.01 Volume 1, "DoD Information Collections Manual: Procedures for DoD Internal Information Collections" before
completing this form.
Visit the DoD Internal Information Collections Website at http://www.dtic.mil/whs/directives/corres/intinfocollections/iic_home.html
for more information on the DoD internal information collections approval process.)
3. TYPE OF REQUEST
1. CLASSIFICATION OF INFORMATION COLLECTION
2. DATE OF REQUEST
(Select one)
(MM/DD/YYYY)
Secret
Unclassified
Top Secret
Confidential
New
Reinstatement
Revision
Extension
4. PRESCRIBING DOCUMENTS
a. DoD ISSUANCE
b. STATUTE OR LAW
c. INTERAGENCY DOCUMENT
d. OTHER DOCUMENTS
This request will be coordinated
with this issuance.
5. INFORMATION COLLECTION DATA
b. EXISTING RCS/OMB CONTROL NUMBER (If applicable)
a. TITLE OF INFORMATION COLLECTION
c. FREQUENCY OF COLLECTION (Select all that apply)
Annually
As Required
Daily
Monthly
One Time
Quarterly
Specify Other
d. RELATED INFORMATION COLLECTION(S)
e. FORM NUMBER(S)
f. TYPE OF COLLECTION INSTRUMENT(S)
(If applicable)
(If applicable)
(Select all that apply and attach a copy of the collection instrument)
Form
Report
Survey
Website
Information System
Focus Group Protocol
Specify Other
6. JUSTIFICATION STATEMENT
Select One:
(Attach as part of the action package)
7. REQUESTING COMPONENT ORGANIZATION NAME AND DIRECTORATE
8. ACTION OFFICER CONTACT INFORMATION
9. REQUESTING COMPONENT OFFICIAL
a. TYPED NAME
a. TYPED NAME
b. OFFICIAL TITLE
b. OFFICIAL TITLE
c. EMAIL ADDRESS
c. SIGNATURE
d. DATE SIGNED
10. ESTIMATED COST OF INFORMATION COLLECTION
a. REFERENCE ID NUMBER
b. FISCAL YEAR
c. TOTAL COST TO REQUESTER
d. TOTAL COST TO RESPONDENT(S)
e. TOTAL COST OF COLLECTION
11. COORDINATION
(1) APPLICABLE?
(2) SIGNATURE
(3) DATE SIGNED
(Yes/No)
Select One:
a. FORMS MANAGER (Forms)
b. OUSD(P&R)/DIRECTOR, DMDC (Surveys)
Select One:
c. HRPP OFFICIAL (Focus groups and research)
Select One:
Yes/Attached
d. PRIVACY OFFICIAL (All collections)
e. RECORDS MANAGER (All collections)
Select One:
Select One:
f. CIO (Electronic format or systems)
12. RESPONDENT(S) COORDINATION (See page 2 of this form)
13. DoD COMPONENT INFORMATION MANAGEMENT CONTROL OFFICER (IMCO)
a. IMCO TYPED NAME
b. IMCO SIGNATURE
c. DATE SIGNED
d. EMERGENCY APPROVAL REQUESTED
Emergency Approval Request
14. FOR USE BY DoD INTERNAL INFORMATION COLLECTIONS OFFICER ONLY
a. RCS
b. OMB CONTROL NUMBER c. EXPIRATION TYPE
d. IICO SIGNATURE
e. DATE SIGNED (MM/DD/YYYY)
DD-
Expiration Date (MM/DD/YYYY)
DD FORM 2936, APR 2014
PREVIOUS EDITION IS OBSOLETE.
Adobe Designer 9.0
12. RESPONDENT(S) COORDINATION (Select and enter amount for all that apply)
Office of the Assistant Secretary of Defense for Legislative Affairs
Office of the Under Secretary of Defense (Comptroller)/Chief Financial
(ASD(LA))
Officer, Department of Defense (USD(C)/DoD CFO)
Cost to the ASD(LA) to respond to this collection
(Includes the Director of the Defense Contract Audit Agency, and the
Office of the Assistant to the Secretary of Defense for Intelligence Oversight
Director of the Defense Finance and Accounting Service)
(ATSD(IO))
Cost to the ATSD(IO) to respond to this collection
Cost to the USD(C) to respond to this collection
Office of the Under Secretary of Defense for Intelligence (USD(I))
Office of the Assistant to the Secretary of Defense for Public Affairs
(ATSD(PA)) (Includes the the Defense Media Activity (DMA))
(Includes the Director of the Defense Intelligence Agency, the Director of
the Defense Security Agency, the Director of the National Geospatial-
Cost to the ATSD(PA) to respond to this collection
Intelligence Agency, the Director of the National Reconnaissance Office,
and the Director of the National Security Agency/Chief of the Central
Office of the Chairman of the Joint Chiefs of Staff (CJCS)
Security Service)
(Includes the Combatant Commands (CCMDs))
Cost to the CJCS to respond to this collection
Cost to the USD(I) to respond to this collection
Office of the Department of Defense Chief Information Officer (DoD CIO)
Office of the Under Secretary of Defense for Personnel and Readiness
(Includes the Defense Information Systems Agency (DISA))
(USD(P&R))
(Includes the Assistant Secretary of Defense (ASD) for Health Affairs, the
Cost to the DoD CIO to respond to this collection
ASD for Readiness and Force Management, the ASD for Reserve Affairs,
the Defense Commissary Agency, the DoD Education Activity, the DoD
Office of the General Counsel of the Department of Defense (GC, DoD)
Human Resources Activity, and the TRICARE Management Activity)
Cost to the DoD GC to respond to this collection
Cost to the USD(P&R) to respond to this collection
Office of the Inspector General of the Department of Defense (IG, DoD)
Office of the Under Secretary of Defense for Policy (USD(P))
(Includes the Assistant Secretary of Defense (ASD) for Asian and Pacific
Cost to the DoD IG to respond to this collection
Security Affairs, the ASD for Global Strategic Affairs, the ASD for Homeland
Defense and America's Security Affairs, the ASD for International Security
Office of the Chief Management Officer (CMO)
Affairs, the ASD for Special Operations and Low Intensity Conflict, the
Defense Security Cooperation Agency, the Defense Prisoner of War/
Cost to the DoD CMO to respond to this collection
Missing Personnel Office, the Defense Technology Security Administration)
Office of the Director of Administration and Management (DA&M)
Cost to the USD(P) to respond to this collection
(Includes Washington Headquarters Services (WHS) and the Pentagon
Force Protection Agency (PFPA))
Identify Other
Cost to the DA&M to respond to this collection
Cost to respond to this collection
Office of the Director of Cost Assessment and Program Evaluation
Identify Other
(DCAPE)
Cost to the DCAPE to respond to this collection
Cost to respond to this collection
Office of the Director of Operational Test and Evaluation (DOT&E)
Identify Other
Cost to the DOT&E to respond to this collection
Cost to respond to this collection
Department of the Air Force
Identify Other
Cost to the Air Force to respond to this collection
Cost to respond to this collection
Department of the Army
Identify Other
Cost to the Army to respond to this collection
Cost to respond to this collection
Department of the Navy
RESPONDENT'S COORDINATION
(Includes Marine Corps)
a. RESPONDING COMPONENT
Cost to the Navy to respond to this collection
Office of the Under Secretary of Defense for Acquisition, Technology, and
Logistics (USD(AT&L))
b. COORDINATING OFFICIAL'S NAME
(Includes the Assistant Secretary of Defense (ASD) for Acquisition, the
ASD for Logistics and Materiel Readiness, the ASD for Nuclear, Chemical,
c. COORDINATING OFFICIAL'S OFFICIAL TITLE
and Biological Defense Programs, the ASD for Research and Engineering,
the ASD for Operational Energy Plans and Programs, the Defense
Advanced Research Projects Agency, the Defense Contract Management
d. COORDINATING OFFICIAL'S SIGNATURE
Agency, the Defense Logistics Agency, the Defense Threat Reduction
Concur
Agency, the Missile Defense Agency, the Defense Technical Information
Do Not Concur
Center, the DoD Test Resource Management Center, the Office of
Economic Adjustment)
e. DATE SIGNED
Cost to the USD(AT&L) to respond to this collection
DD FORM 2936 (BACK), APR 2014
INSTRUCTIONS FOR COMPLETING DD FORM 2936
1. CLASSIFICATION OF COLLECTION. As stated.
5.d. RELATED INFORMATION COLLECTION(S) (If applicable).
List the titles and any identifying numbers (RCS, OMB control number, DD
2. DATE OF REQUEST. Enter date as a 2-digit month followed by 2-
Form number, etc.) for any related information collections.
digit day and 4-digit year (04/02/2012).
e. FORM NUMBER(S) (If applicable). Provide associated form numbers.
Provide temporary form numbers assigned by the DoD or Component Forms
3. TYPE OF REQUEST. Select one:
Manager if the form is awaiting official approval.
“New” - The information collection is new and a Report Control Symbol
f. TYPE OF COLLECTION INSTRUMENT(S). Select all instruments
(RCS) has not been assigned. Complete all sections of this form.
that will be used to collect information and attach a copy of each as part of
the DD Form 2936 action package. Draft copies of the instrument are
“Reinstatement” - The information collection was approved previously
acceptable. Include screenshots and written descriptions for instruments that
but the RCS has expired. Complete all sections of this form.
cannot be attached in their original format (websites, databases, etc.). Select
"Survey" for phone and interview scripts. Select "Survey" and "Website" for
“Revision” - The information collection has an active (not expired) RCS
web-based surveys. Select "Information System" for databases.
and the requesting Component wishes to make changes to the information
collection. For minor changes, contact the DoD Internal Information
6. JUSTIFICATION STATEMENT. Select one:
Collections Officer by sending an email to dod.internal.collect@whs.mil.
Sections 1 through 9 and 13 of this form are mandatory for revision
“New justification statement” - Include the new justification statement as
requests. Complete the remaining sections as applicable (if there is no
part of the DD Form 2936 action package. Microsoft Word documents or
change to the collection instrument, do not complete section 11, etc.).
PDFs are acceptable. A justification statement is a detailed description of
how the information will be used, by whom and the purpose. Does the
“Extension” - The requesting Component is requesting an extension to
information collection involve the use of technological collection techniques;
an existing RCS that has not yet expired. There are no revisions and no
e.g., electronic response submission? Describe efforts made to reduce the
change in the cost of the information collection. Extensions are granted
burden and cost on the respondents.
for a maximum of 2 years. Do not complete sections 10, 11, and 12 of
this form. Complete all other sections.
If the information collection is a survey, attach the package submitted to the
Director, Defense Manpower and Data Center (DMDC). See section 11.b.
for more information on surveys. If the information collection is both a DoD
4. PRESCRIBING DOCUMENTS
internal information collection and a DoD-public information collection,
attach the justification statement provided with the OMB Form 83-I.
a. DoD ISSUANCE. Cite the existing or proposed DoD issuance
prescribing the information collection. Select “This request will be
“Explanation of revisions to information collection” - Provide a detailed
coordinated with this issuance” if respondent coordination will be
description of the revisions instead of composing a justification statement.
obtained during the DoD issuance process. Do not complete section 9 of
Attach as part of the DD Form 2936 action package.
this form if this request will be coordinated with a DoD issuance.
See the DoD Internal Information Collections Website
“Explanation of Request for Extension” - Explain why the extension is
(
)
http://www.dtic.mil/whs/directives/corres/intinfocollections/iic_home.html
necessary. Attach as part of the DD Form 2936 action package.
for guidance on coordinating the DD Form 2936 during the issuance
coordination process.
7. REQUESTING COMPONENT ORGANIZATION NAME AND
DIRECTORATE. As stated.
b. STATUTE OR LAW. If the information collection is required by
law, cite the law or statute (e.g., Sec. 9999 of Public Law 104-13, 10
8. ACTION OFFICER CONTACT INFORMATION. As stated.
United States Code 2678). Attach a copy of the document as part of the
DD Form 2936 action package.
9. REQUESTING COMPONENT OFFICIAL. Do not complete this
section if coordinating the information collection with the prescribing
c. INTERAGENCY DOCUMENT. If the information collection is
issuance. Otherwise the DD Form 2936 must be signed at the Senior
prescribed by a federal agency other than DoD, provide the name of the
Executive Service (SES) level (or equivalent level) at a minimum. The OSD
Federal agency and the prescribing regulation, directive, or other
or DoD Component Head, Principal Deputy, or equivalent level must sign
document (e.g., Treasury Department Regulation XXX). Attach a copy of
the DD Form 2936 for collections costing the requesting DoD or OSD
the document as part of the DD Form 2936 action package.
Component more than $500,000. The requesting Component official must
sign the DD Form 2936 before the DD Form 2936 is submitted to
d. OTHER DOCUMENTS. If the information collection is prescribed
coordination (sections 11 and 12 of this form).
by a DoD document other than a DoD issuance or by a non-DoD
document, provide the title of the document (e.g., Congressional requests
10. ESTIMATED COST OF INFORMATION COLLECTION. Each
not incorporated in Federal statutes and requests from State
request for approval must include an assessment of the projected cost of the
Governments). Attach a copy of the document as part of the DD Form
collection using DoD-approved cost guidance methodology. All requests for
2936 action package.
approval should begin on the DoD Cost Guidance Website at https://www.
cape.osd.mil/CostGuidance/.
5. INFORMATION COLLECTION DATA
a. REFERENCE ID NUMBER. If initiating the DD Form 2936 process
a. TITLE OF INFORMATION COLLECTION. Provide the title of
from the DoD Cost Guidance Website, the cost guidance reference
the information collection as it appears in the prescribing issuance or
identification (ID) number is automatically applied to the DD Form 2936
other prescribing document. Avoid using the year in the title of an
after cost is estimated using the DoD Cost Guidance Website.
information collection if possible.
b. FISCAL YEAR. If initiating the DD Form 2936 process from the DoD
b. EXISTING RCS/OMB CONTROL NUMBER (If applicable).
Cost Guidance Website, the fiscal year is automatically applied to the DD
Provide the existing/previous RCS or Office of Management and Budget
Form 2936 after cost is estimated using the DoD Cost Guidance Website.
(OMB) control number associated with the information collection.
Cost estimates are projected for the first fiscal in which the information will
be collected.
c. FREQUENCY OF COLLECTION (Select all that apply). As stated.
DD FORM 2936 INSTRUCTIONS, APR 2014
INSTRUCTIONS FOR COMPLETING DD FORM 2936
(Continued)
10.c. TOTAL COST TO REQUESTER. If initiating the DD Form 2936
11.f. CIO (Electronic Format or Systems). All DoD internal information
process from the DoD Cost Guidance Website, the total cost of the
collection requests for collection of information via computer systems or in
information collection to the Component requesting the information
electronic format must be coordinated with the requesting Component's
collection is automatically applied to the DD Form 2936 after cost is
Chief Information Officer (CIO) to ensure that the information will be (1)
estimated using the DoD Cost Guidance Website.
appropriately safeguarded; (2) collected, stored and otherwise processed in
information systems that comply with requirements for information
d. TOTAL COST TO RESPONDENT(S). If initiating the DD Form 2936
assurance; and (3) collected and provided in formats and methods that
process from the DoD Cost Guidance Website, the total cost to respondents
ensure accessibility. Attach a copy of this coordination with the DD Form
is the sum of costs to respondents as listed in section 12 of this form and is
2936 action package. Email will suffice. The Component CIO must digitally
automatically applied to the DD Form 2936 after cost is estimated using the
sign in section 11.f.(3) if CIO coordination is applicable.
DoD Cost Guidance Website.
e. TOTAL COST OF COLLECTION. If initiating the DD Form 2936
12. RESPONDENT(S) COORDINATION. If initiating the DD Form
process from the DoD Cost Guidance Website, the total cost of the
2936 process from the DoD Cost Guidance Website, the costs and selection
information collection is the sum of the cost to the requesting Component
of responding Components is automatically applied to the DD Form 2936
(section 10.c. of this form) and the costs to the responding Components
after cost is estimated using the DoD Cost Guidance Website.
(section 10.d. and sum of costs in section 12 of this form). This cost is
automatically applied to the DD Form 2936 after cost is estimated using the
Select “Identify Other” and provide a description in the adjacent blank only
DoD Cost Guidance Website.
if non-DoD entities (e.g., other Federal agencies) will be asked to respond
to the collection. The cost listed in section 12 should only reflect the cost to
11. COORDINATION. It is suggested that coordination be obtained in the
DoD (e.g., there is no cost to the DoD if the Department of State responds to
order as it appears on this form.
a DoD information collection).
(1) APPLICABLE? (Yes/No). See DoD Manual 8910.01 Volume 1 for
required coordination. Indicate whether each area of coordination is
a. RESPONDING COMPONENT. Do not route the DD Form 2936 for
applicable to the information collection.
coordination to responding Components if the information collection will be
approved during formal coordination of its prescribing DoD issuance. See
(2) SIGNATURE. Coordinating officials sign here using electronic
the DoD Internal Information Collections Website
signature.
(http://www.dtic.mil/whs/directives/corres/intinfocollections/iic_home.html)
(3) DATE SIGNED. As stated.
for special instructions to coordinate the DD Form 2936 during formal
coordination of the prescribing issuance. List the DoD Component
a. FORMS MANAGER (Forms). DoD internal information collections
coordinating on the collection (e.g., Navy, USD(AT&L), DA&M).
involving the use of a form must be coordinated with the requesting
Component's Forms Manager to determine if the form should be controlled
b. COORDINATING OFFICIAL'S NAME. Responding Components
in accordance with DoD 7750.07-M. Attach a copy of this coordination with
must coordinate at the SES level (or equivalent level) at a minimum. The
the DD Form 2936 action package. Email will suffice. The Component
DoD or OSD Component Head, Principal Deputy, or equivalent level must
Forms Manager must digitally sign in section 11.a.(2) if the information
sign the DD Form 2936 for collections costing the responding DoD or OSD
collection involves a form.
Component more than $500,000.
b. OUSD(P&R)/DIRECTOR, DMDC (Surveys). All surveys must be
coordinated with the Director, Defense Manpower Data Center (DMDC) in
c. COORDINATING OFFICIAL'S TITLE. As stated.
accordance with DoD Instruction 1100.13. Attach a copy of this coordination
with the DD Form 2936 action package. Email will suffice. A DMDC
d. COORDINATING OFFICIAL'S SIGNATURE. The responding
Official must digitally sign in section 11.b.(2) if the information collection is
Component must select “Concur” or “Do Not Concur” before signing the
a survey.
DD Form 2936 with electronic signature. See the DoD Internal Information
Collections Website
c. HRPP OFFICIAL (Focus Groups and Research). DoD internal
information collections involving the gathering of information on human
(http://www.dtic.mil/whs/directives/corres/intinfocollections/iic_home.html)
subjects must be coordinated with the Human Research Protection Program
for more information on coordinating with responding Components.
(HRPP) Officials in accordance with DoD Directive 3216.02. Attach a copy
of this coordination with the DD Form 2936 action package. Email will
e. DATE SIGNED. As stated
suffice. An HRPP Official must digitally sign in section 11.c.(2) if the
information collection involves human research.
13. DoD COMPONENT INFORMATION COLLECTION
MANAGEMENT CONTROL OFFICER (IMCO). The completed DD
d. PRIVACY OFFICIAL (All Collections). All DoD internal information
Form 2936 action package must be reviewed and coordinated with the
collection requests that contain personally identifiable information must be
requesting Component's IMCO. The IMCO is responsible for reviewing the
coordinated with the requesting Component's Privacy Official to ensure
request to ensure that the information collection is not duplicative of other
compliance with DoD 5400.11-R.. Attach a copy of this coordination with
the DD 2936 action package. Email will suffice. The OSD or Component
information collections and properly coordinated. DD Form 2936 action
Privacy Official must sign in section 11.d.(2).
packages not coordinated with the DoD Component IMCO will not be
approved. “Emergency Approval Request” may only be selected by the
e. RECORDS MANAGER (All Collections). All DoD internal information
Component IMCO. See DoD Manual 8910.01 Volume 1 for a list of
collection requests must be coordinated with the requesting Component's
information collections that may receive emergency approval.
Records Management Official as required to ensure that the appropriate
records disposition schedule has been identified in accordance with the
14. FOR USE BY DoD INTERNAL INFORMATION COLLECTIONS
respective Component's records disposition schedule. Attach a copy of this
OFFICER ONLY. As stated.
coordination with the DD Form 2936 action package. Email will suffice. The
Component Records Manager must digitally sign in section 11.e.(2) if
records coordination is applicable.
DD FORM 2936 INSTRUCTIONS (Page 2), APR 2014

Download DD Form 2936 Request for Approval of DoD Internal Information Collection

759 times
Rate
4.6(4.6 / 5) 222 votes
ADVERTISEMENT
Page of 4