OMB 83-c

Paperwork Reduction Act

Change Worksheet

Agency/Subagency: U.S. Department of Housing and Urban Development			OMB Control Number: 2528-0251
Enter only items that change		Current Record		New Record**
Agency form number(s):      		     		     
Annual reporting and keeping hour burden
	Number of respondents	     		     
	Total annual responses	     		     
	Percent of these responses collected electronically	    %		    %
	Total annual hours	     		     
	Difference			     
	Explanation of difference Program change Adjustment			           
Annual reporting and recordkeeping cost burden (in thousands of dollars)
	Total annualized Capital/Startup costs	     		     
	Total annual costs (O&M)	     		     
	Total annualized cost requested	     		     
	Difference			     
	Explanation of difference Program change Adjustment			           

Other change: **

This change request is being submitted to address the “Terms of Clearance” listed below.

TERMS OF CLEARANCE: This collection is approved for the two pretests only. HUD will submit to OMB the

results of the pretests and any changes in the instruments, or sample size, or methods for approval prior to

conducting the main collection; OMB waives the Federal Register notices for these changes if they are non

substantive in nature. HUD will also submit verification that it has received a certificate of confidentiality from

NIH prior to the main study. After completion of the main study, HUD has agreed to report back to OMB on

achieved response rates and provide copies of methodological reports on the effects of the incentives for

phase II, and on nonresponse bias analyses when those are available.

Signature of Senior Official or Designee: X Wayne Eddins, Departmental Paperwork Reduction Act Officer, OCIO

Date:

For OIRA Use

** This form cannot be used to extend an expiration date.

OMB 83-C 10/95