MS 890, Attachment A

Submission Form for Peace Corps Forms

Creation, Revision, and Re-Approval Process An inter-office form is a form intended for the use of more than one Agency office. This includes any form that collects information from a currently-serving Volunteer. A public-use form is a form that collects information from ten or more members of the public. Individuals other than Peace Corps staff or currently serving Peace Corps Volunteers/Trainees are considered members of the public for this purpose. Public-use forms must be approved by the Office of Management and Budget (OMB). The originating office is responsible for getting all necessary approvals and clearances. The relevant A Delegate, or designee, must approve any proposed form originating from his or her office or sub-offices before the form is cleared/approved for submission to the Records Management Office. Required signatures: Inter-office forms originating office, Office of the General Counsel, Records Management Office Manual section forms originating office, Office of the General Counsel, Records Management Office Public-use form originating office, Office of the General Counsel, Office of Communications, Records Management Office A Privacy Act Statement is required when an individual is asked to provide personal information (name, date of birth, Social Security number, etc.) which will go into a system of records (i.e., the information will be stored and retrieved using the individuals name or other personal identifier). Privacy Act statements must be reviewed by the Privacy/Freedom of Information Act Office and cleared by the Office of the General Counsel.

Originating Office: _____________

(e.g., OHS/MS)

POC:
(First Name) (MI) (Last Name) (Room No.) (Ext.)

Name of Form: _____________________________________________________________________________________ Purpose and Description of use: Is this form similar to another PC form? New Yes (please explain in Purpose) No Not sure Revised Format Review/Re-approve PDF (Word / Excel) Delete Form Savable Peace Corps Manual Section (MS) attachment MS # ________ Attachment ________ Locked Word/Excel (Circle selection) Other (please specify) ______________ Will this form be used to collect information from ten or more members of the public? Yes No Not sure
If not sure, please contact the Records Management Office for clarification.

Coordinating Offices (To be filled out by the Records Management Office) Peace Corps form number: Revised form PC-_________ New form PC- ____________ Requires OMB approval OMB Control No. 0420-__________ Approvals Privacy Act Statement required Form is similar to PC-_________________ Reason justified? Yes No Other ______________________________

Head of Originating Office

Date

Office of Communications

Date

Office of the General Counsel

Date

Records Management Office

Date

PC-2038 (Rev. 06/2013) (Previous editions obsolete)