Defense Logistics Agency Child and Youth Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DLA Form 1855-1F DLA Child and Youth Program Consent to Perform Caregiving Health Practices and Authorization for Disclosure of Health Information	Form	New	Available
Form DLA Form 1855-1E DLA Child and Youth Program Allergy Medical Action Plan	Form	New	Repair queued
Form DLA Form 1855-1D P DLA CYP Diabetes Emergency Medical Action Plan	Form	New	Repair queued
Form DLA Form 1855-1D P DLA CYP Diabetes Daily Medical Action Plan	Form	New	Available
Form DLA Form 1855-1C DLA Child and Youth Program Epilepsy/Seizure Medical Action Plan	Form	New	Repair queued
Form DLA 1855-1B DLA Child and Youth Program Special Diet Statement	Form	New	Available
Form DLA Form 1855-1A DLA Child and Youth Program Respiratory Medical Action Plan	Form	New	Available
Form DLA Form 1855-1 DLA Child and Youth Program (CYP) Health Assessment for Enrollment and Renewal	Form	New	Available
Form DLA Form 1855 DLA Child and Youth Program (CYP) Health/Developmental Screening	Form	New	Repair queued
Form DLA Form 1849-4 DLA CYP Child Illness/Injury Readmission Record	Form	New	Available
Form DLA Form 1849-3 DLA CYP Basic Care Item Consent to Apply	Form	New	Repair queued
Form DLA Form 1849-2 DLA CYP Insect Repellent Use Consent	Form	New	Available
Form DLA Form 1849-1 DLA Child and Youth Program (CYP) Parental Consent for Field Trip	Form	New	Available
Form DLA 1849 Child and Youth Program (CYP) Medication Consent and Administration Log	Form	New	Repair queued
0704-EMLD - SORN S400-20 - 8.21.2018.DOCX	Supplementary Document	Uploaded 2018-11-30	Available
0704-EMLD - SSA - 11.15.2018.docx	Supporting Statement A	Uploaded 2018-11-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
234117	DLA Form 1855-1F	Form	New	DLA Child and Youth Program Consent to Perform Caregiving Health Practices and Authorization for Disclosure of Health Information
234116	DLA Form 1855-1E	Form	New	DLA Child and Youth Program Allergy Medical Action Plan
234115	DLA Form 1855-1D	Form	New	DLA CYP Diabetes Emergency Medical Action Plan
234115	DLA Form 1855-1D	Form	New	DLA CYP Diabetes Daily Medical Action Plan
234113	DLA Form 1855-1C	Form	New	DLA Child and Youth Program Epilepsy/Seizure Medical Action Plan
234112	DLA Form 1855-1B	Form	New	DLA Child and Youth Program Special Diet Statement
234111	DLA Form 1855-1A	Form	New	DLA Child and Youth Program Respiratory Medical Action Plan
234110	DLA CYP Health Screening/Assessment (DLA Forms 1855/1855-1)	Form	New	DLA Child and Youth Program (CYP) Health Assessment for Enrollment and Renewal
234110	DLA CYP Health Screening/Assessment (DLA Forms 1855/1855-1)	Form	New	DLA Child and Youth Program (CYP) Health/Developmental Screening
234109	DLA Form 1849-4	Form	New	DLA CYP Child Illness/Injury Readmission Record
234108	DLA Form 1849-3	Form	New	DLA CYP Basic Care Item Consent to Apply
234107	DLA Form 1849-2	Form	New	DLA CYP Insect Repellent Use Consent
234106	DLA Form 1849-1	Form	New	DLA Child and Youth Program (CYP) Parental Consent for Field Trip
234105	DLA Form 1849	Form	New	Child and Youth Program (CYP) Medication Consent and Administration Log

ICR Details

OMB Control No: 0704-0582	ICR Reference No: 201811-0704-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOW/DODDEP	Agency Tracking No: 0704-EMLD
Title: Defense Logistics Agency Child and Youth Program
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/05/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/11/2018
Terms of Clearance: DOD must report this collection in thier submission to the information collection budget.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2022	36 Months From Approved
Responses	12,055	0	0
Time Burden (Hours)	963	0	0
Cost Burden (Dollars)	21,217	0	0

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Abstract: The Department of Defense (DoD) requires the information in the proposed collection in support of Defense Logistics Agency (DLA) Child and Youth Programs (CYPs). This collection includes fourteen (14) DLA forms, some of which are used by all of the collection respondents and some of which are used under specific circumstances. The information collected is used for program planning, management, and health and safety purposes. More specifically, the information in the proposed collection allows CYP staff to provide safe, developmentally appropriate day care services and to ensure proper, effective response in the event of an emergency. Respondents include patrons enrolling their children in a CYP; these patrons may include active duty military, DoD civilian employees, or DoD contractors.

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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:
	83 FR 46485	09/13/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 59369	11/23/2018
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
DLA CYP Health Screening/Assessment (DLA Forms 1855/1855-1)	DLA Form 1855, DLA Form 1855-1	DLA Child and Youth Program (CYP) Health/Developmental Screening ,   DLA Child and Youth Program (CYP) Health Assessment for Enrollment and Renewal
DLA Form 1849	DLA 1849	Child and Youth Program (CYP) Medication Consent and Administration Log
DLA Form 1849-1	DLA Form 1849-1	DLA Child and Youth Program (CYP) Parental Consent for Field Trip
DLA Form 1849-2	DLA Form 1849-2	DLA CYP Insect Repellent Use Consent
DLA Form 1849-3	DLA Form 1849-3	DLA CYP Basic Care Item Consent to Apply
DLA Form 1849-4	DLA Form 1849-4	DLA CYP Child Illness/Injury Readmission Record
DLA Form 1855-1A	DLA Form 1855-1A	DLA Child and Youth Program Respiratory Medical Action Plan
DLA Form 1855-1B	DLA 1855-1B	DLA Child and Youth Program Special Diet Statement
DLA Form 1855-1C	DLA Form 1855-1C	DLA Child and Youth Program Epilepsy/Seizure Medical Action Plan
DLA Form 1855-1D	DLA Form 1855-1D Part 2, DLA Form 1855-1D Part 1	DLA CYP Diabetes Daily Medical Action Plan ,   DLA CYP Diabetes Emergency Medical Action Plan
DLA Form 1855-1E	DLA Form 1855-1E	DLA Child and Youth Program Allergy Medical Action Plan
DLA Form 1855-1F	DLA Form 1855-1F	DLA Child and Youth Program Consent to Perform Caregiving Health Practices and Authorization for Disclosure of Health Information

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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	12,055	0	0	0	12,055	0
Annual Time Burden (Hours)	963	0	0	0	963	0
Annual Cost Burden (Dollars)	21,217	0	0	0	21,217	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: This is an existing collection currently in use without an OMB Control Number.

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Annual Cost to Federal Government: $10,322

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 12/11/2018

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