Department of State Mentor-Protege Program Application

Forms and Documents

Document Name	Status
Form DS-4053 Department of State Mentor-Protege Program Application Form	Modified
Final - Supporting Statement 30-Day (7-2014).docx Supporting Statement A	2014-08-11
1405-0161 Legal Authorities (5-14).docx Supplementary Document	2014-05-12

IC Document Collections

IC ID	Document Title	Status
38774	Department of State Mentor-Protege Program Application Form	Modified

ICR Details

OMB Control No: 1405-0161	ICR Reference No: 201405-1405-001
Status: Historical Active	Previous ICR Reference No: 201105-1405-005
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Department of State Mentor-Protege Program Application
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/11/2014
	Date Received in OIRA: 05/12/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	36 Months From Approved	08/31/2014
Responses	20	0	14
Time Burden (Hours)	240	0	294
Cost Burden (Dollars)	40	0	0

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Abstract: The U.S. Department of State is implementing a Mentor-Protege Program that encourages agreements between large (and small) business prime contractor mentors and eligible small business proteges. To execute the program, business related data must be collected and evaluated from each memtor-protege team.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 69171	11/18/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 27029	05/12/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Department of State Mentor-Protege Program Application	DS-4053	Department of State Mentor Protégé Program Application

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ICR Summary 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	20	14	0	0	6	0
Annual Time Burden (Hours)	240	294	0	0	-54	0
Annual Cost Burden (Dollars)	40	0	0	0	40	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: Burden changes are due changes in number of respondents and updated cost burden

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Annual Cost to Federal Government: $5,160

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 05/12/2014

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