Regional Resource Center Monthly Report Form

Counseling Information Form; Regional Center Intake Form and Monthly Report of Operations Form.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2105-0554 can be found here:

Documents and Forms

Document Name Document Type
Form DOT F 4500 Regional Resource Center Monthly Report Form Form
DOT F 4500 The Regional Center Intake Form DOT F 4500.pdf Form

Information Collection (IC) Details

IC Title:	Regional Resource Center Monthly Report Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 49 CFR 23 49 CFR 26

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DOT F 4500	The Regional Center Intake Form	DOT F 4500.pdf		Yes	No	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 100

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,200	-9,150	10,350
Annual IC Time Burden (Hours)	600	-3,711	4,311
Annual IC Cost Burden (Dollars)	0	0	0

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.