SF-424 Project/Performance Site Location(s) Form; Key Contacts; Project Abstract

Forms and Documents

Document	Type	Status	Availability
Form 4040-0010 Project Performance Site Location	Form	New	Available
Form 4040-0010 Project Abstract	Form	New	Repair queued
Form 4040-0010 Key Contacts	Form	Modified	Repair queued
4040-0010 ICR SS.docx	Supporting Statement A	Uploaded 2016-09-14	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
223157	Project Performance Site Location	Form	New
223156	Project Abstract	Form	New
185702	Key Contacts	Form	Modified

ICR Details

OMB Control No: 4040-0010	ICR Reference No: 201608-4040-012
Status: Historical Active	Previous ICR Reference No: 201307-4040-008
Agency/Subagency: EGOV	Agency Tracking No: 15380
Title: SF-424 Project/Performance Site Location(s) Form; Key Contacts; Project Abstract
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/01/2016
	Date Received in OIRA: 09/20/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved	11/30/2016
Responses	6,279	0	137,818
Time Burden (Hours)	6,279	0	68,909
Cost Burden (Dollars)	0	0	0

---

Abstract: In compliance with section 3507(a)(1)(D) of the Paperwork Reduction Act of 1995, the Electronic Government Office (EGOV), Department of Health and Human Services, has submitted an Information Collection Request (ICR), described below, to the Office of Management and Budget (OMB) for review and approval. The ICR is for reinstatement of a previously-approved information collection assigned OMB control number 4040-0010, which expired on August 31, 2011. The ICR also requests categorizing the form as a common form, meaning HHS will only request approval for its own use of the form rather than aggregating the burden estimate across all Federal Agencies as was done for previous actions on this OMB control number.

---

Authorizing Statute(s): PL: Pub.L. 106 - 107 468 Name of Law: Federal Financial Assistance Management Improvement Act of 1999
   PL: Pub.L. 109 - 282 2590 Name of Law: Federal Funding Accountability and Transparency Act of 2006
  

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:
	81 FR 9487	02/25/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 39933	06/20/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Key Contacts	4040-0010	Key Contacts
Project Performance Site Location	4040-0010	Project/Performance Site Location
Project Abstract	4040-0010	Project Abstract

---

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	6,279	137,818	0	-131,539	0	0
Annual Time Burden (Hours)	6,279	68,909	0	-62,630	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The use of the Project Performance Site Location, Key Contacts Form, and the Project Abstract is at the discretion of the agency.

---

Annual Cost to Federal Government: $244,881

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]? Yes

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)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  Yes

OIRA authorizes any Agency to begin using a Common Form associated with this ICR automatically after 5 calendar days from the date the agency's RCF including the common form was received in OIRA.

Description/Changes for Common Form Usage:  This form meets the definition of a Common Form as it is used by more than one Federal grant-making agency

Approved RCFs using this ICR

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title
USDA/NIFA	201701-0524-066CF	Key Contracts and Project/Performance Site Locations(s)	Historical Active	Key Contacts, Project Performance Site Location
DOL/DM	201703-1225-013CF	SF-424 Project/Performance Site Location(s) Form; Key Contacts; Project Abstract --DOL Usage	Historical Active	Key Contacts, Project Abstract, Project Performance Site Location
TREAS/DO	201901-1505-002CF	Application, Reports, and Recordkeeping for the Social Impact Partnerships to Pay for Results Act (SIPPRA) grant program.	Historical Active	Project Performance Site Location
DOT/FMCSA	201901-2126-003CF	Key Contacts	Historical Active	Key Contacts
DOD/DODDEP	201802-0704-006CF	SF-424 Project/ Performance Site Location(s) Form; Key Contacts; Project Abstract	Historical Active	Project Performance Site Location
TREAS/DO	201811-1505-004CF	Social Impact Partnerships to Pay for Results Act (SIPPRA) grant program	Historical Active	Key Contacts, Project Abstract

---

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: 09/20/2016

---