Food Distribution Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SF 425 Financial Status Reports- ARRA FDPIR	Form	Modified	Repair queued
Form FNS-667 REPORT OF THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) ADMINISTRATIVE COSTS	Form	Modified	Available
Form FNS-155 INVENTORY MANAGEMENT REGISTER	Form	Modified	Available
Form FNS-153 MONTHLY REPORT OF THE COMMODITY SUPPLEMENTAL FOOD PROGRAM AND QUARTERLY ADMINISTRATIVE FINANCIAL STATUS REPORT	Form	Modified	Available
Form FNS-152 MONTHLY DISTRIBUTION OF DONATED FOODS TO FAMILY UNITS	Form	Modified	Available
Form FNS-57 REPORT OF SHIPMENT RECEIVED OVER, SHORT AND/OR DAMAGED	Form	Modified	Available
Form FNS-53 USDA MULTI-FOOD REQUISITION	Form	Modified	Available
Form FNS-52 FOOD REQUISITION	Form	Modified	Repair queued
Form FNS-7 DESTINATION DATA FOR DELIVERY OF DESTINATION DATA FOR DELIVERY OF	Form	Modified	Available
Form FNS-663 FOOD DISTRIBUTION COMMODITY ACCEPTABILITY PROGRESS (CAP) REPORT	Form and Instruction	New	Available
03 WBSCM Screenshot - Consolidated Requisition Form (250 58).doc	Supplementary Document	Uploaded 2009-11-30	Available
06 WBSCM Screenshot - Complaints Form (250 22).doc	Supplementary Document	Uploaded 2009-11-30	Available
05 WBSCM Screenshot - Recall Survey Response Form (250 17e) (2).doc	Supplementary Document	Uploaded 2009-11-30	Available
04 WBSCM Screenshot - Shipment Receipt Form (250 13f).doc	Supplementary Document	Uploaded 2009-11-30	Available
02 WBSCM Screenshot - Multi-Food Order Form (250 13f).doc	Supplementary Document	Uploaded 2009-11-30	Available
01 WBSCM Screenshot - Domestic Direct Ship Order Form (250 58).doc	Supplementary Document	Uploaded 2009-11-30	Available
Supporting Statement 0584-0293.docx	Supporting Statement A	Uploaded 2009-11-30	Available
Burden_Table 2009 Renewal Final Table 11-24-09.xlsx	Supplementary Document	Uploaded 2009-11-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43552	Food Distribution Forms (State and Local Government)	Form	Modified	Financial Status Reports- ARRA FDPIR
43552	Food Distribution Forms (State and Local Government)	Form	Modified	REPORT OF THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) ADMINISTRATIVE COSTS
43552	Food Distribution Forms (State and Local Government)	Form	Modified	INVENTORY MANAGEMENT REGISTER
43552	Food Distribution Forms (State and Local Government)	Form	Modified	MONTHLY REPORT OF THE COMMODITY SUPPLEMENTAL FOOD PROGRAM AND QUARTERLY ADMINISTRATIVE FINANCIAL STATUS REPORT
43552	Food Distribution Forms (State and Local Government)	Form	Modified	MONTHLY DISTRIBUTION OF DONATED FOODS TO FAMILY UNITS
43552	Food Distribution Forms (State and Local Government)	Form	Modified	REPORT OF SHIPMENT RECEIVED OVER, SHORT AND/OR DAMAGED
43552	Food Distribution Forms (State and Local Government)	Form	Modified	USDA MULTI-FOOD REQUISITION
43552	Food Distribution Forms (State and Local Government)	Form	Modified	FOOD REQUISITION
43552	Food Distribution Forms (State and Local Government)	Form	Modified	DESTINATION DATA FOR DELIVERY OF DESTINATION DATA FOR DELIVERY OF
191243	Individuals/Households - Elderly & WIC		New
191242	Business	Form and Instruction	New	FOOD DISTRIBUTION COMMODITY ACCEPTABILITY PROGRESS (CAP) REPORT

ICR Details

OMB Control No: 0584-0293	ICR Reference No: 200911-0584-003
Status: Historical Active	Previous ICR Reference No: 200906-0584-004
Agency/Subagency: USDA/FNS	Agency Tracking No:
Title: Food Distribution Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/31/2009
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/30/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2012	36 Months From Approved	12/31/2009
Responses	1,655,720	0	1,160,746
Time Burden (Hours)	1,079,172	0	1,073,701
Cost Burden (Dollars)	0	0	0

---

Abstract: To assist American farmers and needy people by purchasing commodities and delivering them to State agencies that, in turn, distribute them to organizations for use in providing food assistance to those in need.

---

Authorizing Statute(s): US Code: 42 USC 1755, 1762a & 1776 Name of Law: National School Lunch Act
   US Code: 7 USC 2013 Name of Law: Food Stamp Act 1977
   US Code: 42 USC Section 4 (1733) Name of Law: Child Nutrition Act 1966
   US Code: 7 USC 7501 Name of Law: The Emergency Food Assistance Act 1983
   PL: Pub.L. 111 - 5 101 Name of Law: American Recovery and Reinvestment Act of 2009
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 41108	08/14/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 228	11/30/2009
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Business	FNS-663	FOOD DISTRIBUTION COMMODITY ACCEPTABILITY PROGRESS (CAP) REPORT
Food Distribution Forms (State and Local Government)	SF 425, FNS-7, FNS-152, FNS-52, FNS-53, FNS-57, FNS-153, FNS-155, FNS-667	DESTINATION DATA FOR DELIVERY OF DESTINATION DATA FOR DELIVERY OF ,   FOOD REQUISITION ,   USDA MULTI-FOOD REQUISITION ,   REPORT OF SHIPMENT RECEIVED OVER, SHORT AND/OR DAMAGED ,   MONTHLY DISTRIBUTION OF DONATED FOODS TO FAMILY UNITS ,   MONTHLY REPORT OF THE COMMODITY SUPPLEMENTAL FOOD PROGRAM AND QUARTERLY ADMINISTRATIVE FINANCIAL STATUS REPORT ,   INVENTORY MANAGEMENT REGISTER ,   REPORT OF THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) ADMINISTRATIVE COSTS ,   Financial Status Reports- ARRA FDPIR
Individuals/Households - Elderly & WIC

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,655,720	1,160,746	0	0	494,974	0
Annual Time Burden (Hours)	1,079,172	1,073,701	0	51	5,420	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The revision in burden hours under Section 250 reflects program changes caused as a result of the upcoming implementation of a new Web Based Supply Change Management (WBSCM) system, which will replace older systems and will streamline the procurement, delivery, and management of USDA foods. A net increase of 5,420 hours is due to the implementation of WBSCM. We are also requesting 51 hours due to changes in the certification process created by the final rule Food Distribution Program on Indian Reservations: Resource Limits and Exclusions, and Extended Certification Periods. The current OMB Inventory is 1,073,701 with the increase the total Annual Hours Requested is 1,079,172.

---

Annual Cost to Federal Government: $5,579,557

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/30/2009

---