Information Collection

Child Wellness

IC 192209 under ICR 201203-0584-001 · OMB 0584-0512.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0512 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
AD1047-F-01-92.pdf Certification Regarding Debarment, Suspension, and Other	IC Document
AD1048-F-01-92.pdf Certification Regarding Debarment, Suspension, Ineligibility	IC Document
AD-1052.pdf AD-1052, Certification Regarding Drug-Free Workplace	IC Document
SS_Justification_3-10-2010.doc Supporting Statement	IC Document
FY2010 Child Care Wellness Grant RFA (final draft) 1-27-10.docx Request for Applications	IC Document
Request fo Approval to Add Grant to OMB Docket.doc Memo	IC Document
sflllin.pdf SF - LLL	IC Document
SF424.pdf SF-424	IC Document
sf424a.pdf SF-424A	IC Document
sf424b.pdf SF-424B	IC Document
SF-425 (fillable).pdf SF-425	IC Document

IC Title:

Child Wellness

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 7 CFR 3017

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	2,110	2,110
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Certification Regarding Debarment, Suspension, and Other	AD1047-F-01-92.pdf	03/09/2010
Certification Regarding Debarment, Suspension, Ineligibility	AD1048-F-01-92.pdf	03/09/2010
AD-1052, Certification Regarding Drug-Free Workplace	AD-1052.pdf	03/10/2010
Supporting Statement	SS_Justification_3-10-2010.doc	03/11/2010
Request for Applications	FY2010 Child Care Wellness Grant RFA (final draft) 1-27-10.docx	03/09/2010
Memo	Request fo Approval to Add Grant to OMB Docket.doc	03/10/2010
SF - LLL	sflllin.pdf	03/11/2010
SF-424	SF424.pdf	03/11/2010
SF-424A	sf424a.pdf	03/11/2010
SF-424B	sf424b.pdf	03/11/2010
SF-425	SF-425 (fillable).pdf	03/11/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.