Suspension and Debarment and Drug-Free Workplace Certifications

Forms and Documents

Document Name	Status
Form AD-1047 Suspension and Debarment and Drug-Free Workplace Certifications Form and Instruction	New
Q-8 Appendix 1 Responses SDDFWP Certs.xlsx Supplementary Document	2015-07-22
SuptStmt Final (USDA SD DFWP Certs)_v.3.docx Supporting Statement A	2015-11-16

IC Document Collections

IC ID	Document Title	Status
217590	Suspension and Debarment and Drug-Free Workplace Certifications Form and Instruction	New

ICR Details

OMB Control No: 0505-0027	ICR Reference No: 201507-0505-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: USDA/OCFO	Agency Tracking No:
Title: Suspension and Debarment and Drug-Free Workplace Certifications
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/01/2015
	Date Received in OIRA: 07/23/2015
Terms of Clearance: Agencies must account for the full burden of these forms in subsequent Information Collection requests for their particular programs. This applies to both new collections and previously approved collections. Agencies must account for the full burden of these forms as collections expire and come in for OMB review. In any new or previously approved collection that uses these forms, the OMB Control Number and expiration date from this collection must be displayed.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2018	36 Months From Approved
Responses	1	0	0
Time Burden (Hours)	1	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: To certify information on applicant suitability concerning distribution of financial assistance in compliance with Federal Suspension and Debarment and Drug-Free Workplace regulations.

---

Authorizing Statute(s): None

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:
	79 FR 71084	12/01/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 42788	07/20/2015
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Suspension and Debarment and Drug-Free Workplace Certifications	AD-1047, AD-1048, AD-1049, AD-1050, AD-1052	Certification Regarding Debarment, Suspension, and Other Responsibility Matters Primary COvered Transactions ,   Cdrtification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions ,   Certification Regarding Drug-Free Workplace Requirements (Grants) Alternative I - For Grantee Other Than Individuals ,   Certofocatopm Regarding Drug-Free Workplace Requirements (Grants) Alternative II - For Grantees Who are Individuals ,   Certification Regarding Drug-Free Workplace State and State Agencies, Federal Fiscal Year

---

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	1	0	0	1	0	0
Annual Time Burden (Hours)	1	0	0	1	0	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: This is a new information collection. The burden estimate for this collection is solely attributed to the fact that the forms will be used throughout USDA. The one hour burden estimate thus reflects only the burden associated with OCFO's use of the form rather than aggregating the form's usage across all USDA agencies and staff offices

---

Annual Cost to Federal Government: $0

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

---

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: 07/23/2015

---