Head Start Eligibility Verification

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 1305.4(l) Eligibility determination records (sample form)	Form and Instruction	New	Repair queued
Form 0 Head Start Eligibility Verfication Form	Form and Instruction	Removed	Available
HS_Eligibility_Verification_Form_Supporting_Statement_12-2-15.docx	Supporting Statement A	Uploaded 2015-12-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
219444	1305.4(l) Other Record Keeping		New
219443	1305.4(h),(i),, and (j)		New
219442	1305.4(d)(2)		New
219441	1305.4(l) Eligibility determination records (sample form)	Form and Instruction	New
191567	Head Start Eligibility Verfication Form	Form and Instruction	Removed

ICR Details

OMB Control No: 0970-0374	ICR Reference No: 201512-0970-004
Status: Historical Active	Previous ICR Reference No: 201211-0970-003
Agency/Subagency: HHS/ACF	Agency Tracking No: OHS
Title: Head Start Eligibility Verification
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: 03/10/2016
	Date Received in OIRA: 12/31/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved	03/31/2016
Responses	768,020	0	1,200,000
Time Burden (Hours)	124,520	0	96,000
Cost Burden (Dollars)	0	0	0

---

Abstract: The requirements for establishing proof of eligibility for the enrollment of children in Head Start programs are documented in 45 CFR 1305.4 (e). The regulation states that each child's record must include a signed document by an employee identifying those documents which were reviewed to determine eligibility and stating that the child is eligible to participate in the program. Presently there is no standardized document for grantees to use. This form will be used to facilitate an efficient and accurate determination and documentation of childrens' eligibility for Head Start.

---

Authorizing Statute(s): US Code: 45 USC 1305.4 Name of Law: Public Welfare
  

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:
	80 FR 57828	09/25/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 80772	12/28/2015
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
1305.4(d)(2)
Head Start Eligibility Verfication Form	0	Head Start Eligibility Verification
1305.4(l) Eligibility determination records (sample form)	1	Sample eligibility form
1305.4(h),(i),, and (j)
1305.4(l) Other Record Keeping

---

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	768,020	1,200,000	0	-431,980	0	0
Annual Time Burden (Hours)	124,520	96,000	0	28,520	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: Changing Regulations

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: New regulation created program change.

---

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: 12/31/2015

---