Senior Community Service Employment Program Performance Measurement System

Forms and Documents

Document Name	Status
Form Eta 9120 SCSEP Participant Data Form (State) Form	Unchanged
Form ETA-9123 SCSEP Exit Form (National) Form	Unchanged
Form ETA 9123 SCSEP Exit Form (State) Form	Unchanged
Form ETA 9122 SCSEP Unsubsidized Employment Form (National) Form	Modified
Form ETA 9122 SCSEP Unsubsidized Employment Form (State) Form	Modified
Form ETA 9121 SCSEP Community Service Assignment Form (National) Form	Modified
Form ETA 9121 SCSEP Community Service Assignment Form (State) Form	Modified
Form ETA 9120 SCSEP Participant Data Form (National) Form	Unchanged
Form ETA-8705 SCSEP Equitable Distribution Report Form	Unchanged
Form ETA 9124B SCSEP Employer and Host Agency Customer Satisfaction Surveys Form and Instruction	Unchanged
JUSTIFICATION.docx Justification for No Material/Nonsubstantive Change	2016-08-04
OMB JUSTIFICATION_STATE PLAN TEGL 3.21.16.docx Justification for No Material/Nonsubstantive Change	2016-03-21
1205-0040_SupportPartB_FINAL_edited_3-23-2015.doc Supporting Statement B	2015-03-23
Approval - Statistical Clearance.3232015.pdf Supplementary Document	2015-03-23
1205-0040_SupportPartA_FINAL07-2015.doc Supporting Statement A	2015-07-29

IC Document Collections

IC ID	Document Title	Status
43785	SCSEP Participant Data Form (State) Form	Unchanged
215838	Quarterly Narrative Progress Report Other-Quarterly Narrative Progress Report	Unchanged
185407	SCSEP Four-Year State Strategy Instruction	Unchanged
181013	SCSEP Exit Form (National) Form	Unchanged
181011	SCSEP Exit Form (State) Form	Unchanged
181010	SCSEP Unsubsidized Employment Form (National) Form	Modified
181009	SCSEP Unsubsidized Employment Form (State) Form	Modified
181008	SCSEP Community Service Assignment Form (National) Form	Modified
181007	SCSEP Community Service Assignment Form (State) Form	Modified
180574	SCSEP Participant Data Form (National) Form	Unchanged
180499	SCSEP Equitable Distribution Report Form	Unchanged
180160	SCSEP Employer and Host Agency Customer Satisfaction Surveys Form and Instruction	Unchanged

ICR Details

OMB Control No: 1205-0040	ICR Reference No: 201608-1205-001
Status: Historical Inactive	Previous ICR Reference No: 201603-1205-006
Agency/Subagency: DOL/ETA	Agency Tracking No:
Title: Senior Community Service Employment Program Performance Measurement System
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 09/21/2016
	Date Received in OIRA: 08/09/2016
Terms of Clearance: This change request is withdrawn per DOL's request. Prior terms remain in effect. Agency made updates to supporting statement to reflect changes to instruments as well as a notation to reflect the extension of pilot grants through December 2015. After these grants expire, the Department will submit a non-material change request to discontinue the use of these fields in the instruments associated with these grants.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2018	08/31/2018	11/30/2018
Responses	232,520	0	232,520
Time Burden (Hours)	32,922	0	32,922
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection contains program performance reports required for monitoring the Senior Community Service Employment Program (SCSEP). The current request is for an extension with the addition of a request for approval of an additional participant data indicator: participants' volunteer efforts.

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Authorizing Statute(s): PL: Pub.L. 109 - 365 501-518 Name of Law: Older Americans Act Amendments of 2006
  

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:
	79 FR 65705	11/05/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 16457	03/27/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 12

IC Title	Form No.	Form Name
SCSEP Community Service Assignment Form (State)	ETA 9121	Community Service Assignment Form
SCSEP Community Service Assignment Form (National)	ETA 9121	Community Service Assignment Form
SCSEP Exit Form (State)	ETA 9123	SPARQ Exit Form
SCSEP Participant Data Form (State)	Eta 9120	SPARQ Participant Form
Quarterly Narrative Progress Report
SCSEP Employer and Host Agency Customer Satisfaction Surveys	ETA 9124C, ETA 9124B, ETA-9124-A	Host Agency Customer Satisfaction Survey ,   Employer Customer Satisfaction Survey ,   SCSEP Participant Survey Customer Satisfaction
SCSEP Equitable Distribution Report	ETA-8705	Equitable Distribution Report
SCSEP Participant Data Form (National)	ETA 9120	SPARQ Participant Form
SCSEP Four-Year State Strategy
SCSEP Unsubsidized Employment Form (State)	ETA 9122	Unsubsidized Employment Form
SCSEP Exit Form (National)	ETA-9123	SPARQ Exit Form
SCSEP Unsubsidized Employment Form (National)	ETA 9122	Unsubsidized Employment Form

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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:

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Annual Cost to Federal Government: $65,713

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 08/09/2016

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