Information Collection

School Wellness Policy Cooperative Agreement

IC 211924 under ICR 201209-0584-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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
LWP RFA 6-19-2014.docx	Other-Request for Application
Terms and Conditions - FINAL.docx Terms and Conditions	IC Document
AD1049-F-05-90.pdf CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS (GRANTS)	IC Document
AD1050-F-01-92.pdf CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS (GRANTS)	IC Document
RR_FedNonFedBudget-V1.1.pdf Research and Related Budget _FedNonFedBudget	IC Document
RR_SubawardBudget_1_3-V1.3.pdf R&R Sub Award Budget	IC Document
SF424_2_1-V2.1.pdf Application for Federal Assistance	IC Document
sflll.pdf Disclosure of Lobbying Activities	IC Document
Request to OMB to Use 0584-0512 (Local Child Nutrition Wellness Grant) 7-11-14.docx Generic Clearance Justification Memo	IC Document
0512 LWP Grant Program_Supporting Statement 6-20-14.docx Local Wellness Program Generic Supporting Statement	IC Document
SF-425 screenshot July 2013.docx SF 425 FEDERAL FINANCIAL REPORT	IC Document
AD1047-F-01-92.PDF Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions	IC Document
AD1048-F-01-92.PDF Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions	IC Document
AD-1052.pdf CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS, STATE AND STATE AGENCIES	IC Document

IC Title:

School Wellness Policy Cooperative Agreement

Agency IC Tracking Number:

Local Wellness

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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
Other-Request for Application				www.grants.gov	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	21	21
Annual IC Time Burden (Hours)	430	430
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Terms and Conditions		06/16/2014
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS (GRANTS)		06/19/2014
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS (GRANTS)		06/19/2014
Research and Related Budget _FedNonFedBudget		06/20/2014
R&R Sub Award Budget		06/20/2014
Application for Federal Assistance		06/20/2014
Disclosure of Lobbying Activities		06/20/2014
Generic Clearance Justification Memo		07/11/2014
Local Wellness Program Generic Supporting Statement		06/20/2014
SF 425 FEDERAL FINANCIAL REPORT		07/02/2014
Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions		07/15/2014
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions		07/15/2014
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS, STATE AND STATE AGENCIES		07/15/2014

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

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