“Defense Logistics Agency Child and Youth Program”
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.
Listed below are the DLA forms associated with this collection:
DLA Form 1849, “CYP Medication Consent and Administration Log”
Completion of this form is required for all patrons with a child requiring medication to be administered during child care operating hours by the CYP staff. This form collects information specifying the right medication, route, child, and amount and time for the medication to be administered. Additionally, completion of the form serves as the consent from the guardian of the child. This form is completed every 90 days that the medication is required to be administered.
DLA Form 1849-1, “DLA CYP Parental Consent for Field Trip”
Completion of this form is required for patrons to give consent for their child to attend a field trip. Information regarding the place, time, contact information, staff attending, child’s name, and special instructions is gathered and the signature serves as consent from the guardian for the child to attend. This form is completed prior to each field trip.
DLA Form 1849-2, “DLA CYP Insect Repellant Use Consent”
Completion of this form is required for all patrons who have a child requiring insect repellant to be applied during child care operating hours by the CYP staff. This form is completed one time upon determination that insect repellant will be needed during CYP operating hours.
DLA Form 1849-3, “DLA CYP Basic Care Item Consent to Apply”
Completion of this form is required for all patrons who have a child requiring basic care items such as diaper cream, sunscreen, lip balm, etc. to be administered during child care operating hours by the CYP staff. This form collects information specifying the care item, route, child, and amount and time for the basic care item to be administered. Additionally, completion of the form serves as the consent from the guardian of the child. This form is completed every 90 days that the basic care item is required to be administered.
DLA Form 1849-4, “DLA CYP Child Illness/Injury Readmission Record”
Completion of this form is required for all patrons who have a child requiring dismissal from a CYP due to suspected illness. This form specifies the suspected illness, the requirements for returning the child to care, and the diagnosis and treatment required by the physician. This form is completed each time a child requires dismissal due to suspected illness.
DLA Form 1855, “DLA CYP Health/Developmental Screening”
Completion of this form is required for all patrons enrolling a child in a CYP. This form collects information specifying the child’s health-related conditions and restrictions and recommendations/training required to occur in the CYP for the child to safely attend group child care. This form is completed annually.
DLA Form 1855-1, “DLA CYP Health Assessment for Enrollment and Renewal”
Completion of this form is required for all patrons enrolling a child in a CYP. This form collects information specifying the child’s medical history, on-going medications, and physical exam completed by the child’s physician. This form is either re-signed with “no changes” annually or completed again each year of changes occur.
DLA Form 1855-1A, “DLA CYP Respiratory Medical Action Plan”
Completion of this form is required for all patrons enrolling a child in a CYP who requires rescue medications to treat a respiratory illness. This form collects information specifying the respiratory triggers and symptoms, medication/treatments plans, and emergency response needed in the event of a respiratory attack. This form is completed annually.
DLA Form 1855-1B, “DLA CYP Special Diet Statement”
Completion of this form is required for all patrons enrolling a child in a CYP who has a food allergy or intolerance requiring a specialized diet or substitution. This form collects information specifying the foods to be omitted, reactions if ingested, and authorized food substitutions required for the child to safely attend group child care. This form is completed annually.
DLA Form 1855-1C, “DLA CYP Epilepsy/Seizure Medical Action Plan”
Completion of this form is required for all patrons enrolling a child in a CYP who is diagnosed with epilepsy or seizures. This form collects information specifying the febrile seizure prevention plan, symptoms of the child’s seizure, the medication/treatment plan, and the emergency response needed in the event of a seizure. This form is completed annually.
DLA Form 1855-1D, Part I, “DLA CYP Diabetes Daily Medical Action Plan”
Completion of this form is required for all patrons enrolling a child in a CYP who is diagnosed with diabetes. This form collects information specifying the daily care requirements and treatments for the child. This form is completed annually.
DLA Form 1855-1D, Part II, “DLA CYP Diabetes Emergency Medical Action Plan”
Completion of this form is required for all patrons enrolling a child in a CYP who is diagnosed with diabetes. This form collects information specifying the symptoms of a diabetic reaction and the emergency response needed. This form is completed annually.
DLA Form 1855-1E, “DLA CYP Allergy Medical Action Plan”
Completion of this form is required for all patrons enrolling a child in a CYP who requires rescue medications to treat a diagnosed allergy. This form collects information specifying the medication protocol, the treatment plan, and the emergency response needed in the event of an allergic reaction. This form is completed annually.
DLA Form 1855-1F, “DLA CYP Consent to Perform Caregiving Health Practices and Authorization for Disclosure of Health Information”
Completion of this form is required for all patrons enrolling a child in a CYP who requires one or more medical action plan(s).
Authority for this collection of information is drawn from the following:
5 U.S.C. 301, “Departmental Regulations”
10 U.S.C. 133, “Under Secretary of Defense for Acquisition, Technology, and Logistics”
10 U.S.C. 2809 and 2812, “Military construction of child care facilities”
42 U.S.C. 127, “Coordinated services for children, youth, and families”
40 U.S.C. 490b, “Child care services for Federal employees”
42 U.S.C. 67, “Child abuse programs”
P.L. 101-89, Title XV, “Military Child Care Act of 1989”
DoD Instruction 6060.2, “Child Development Programs”
At the time a patron’s child is ready to be enrolled in a CYP, the patron is provided DLA Form 1855 via email. After completing the form, the patron emails the form back to the CYP facility. Next, the facility will place an introductory call to the patron and provide guidance on next steps. Based on the information provided on DLA Form 1855, the patron may be required to complete additional forms to accommodate special needs or medical requirements for the child to be enrolled. These additional forms are also emailed from the patron to the CYP facility.
Upon receiving completed forms from patrons, CYP staff print the forms and file them by the child’s name in secure filing cabinets. For the purpose of determining staff training needs, appropriate classroom placement, necessity of contract modification, and appropriate follow-up (to include collaboration with community resources), certain records will be made available to members of the Inclusion Action Team (IAT). Such information includes records pertaining to: physical abilities and limitations; physical, emotional, or other special care requirements, to include restrictions or special precautions concerning diet; existing Individual Education Programs; and documentation of behavioral issues or other special needs. Based upon the severity of a child’s special need, the fact of the child’s enrollment at the CYP and the nature of his or her condition will be provided to the installation’s paramedic squad in the event medical attention is ever needed. Records may also be made available to subject matter experts during inspections.
Information collected may be shared on a need-to-know basis within the DoD. Pursuant to 5 U.S.C. 522a(b)(3) and (8), these records may also be disclosed outside DoD to physicians, dentists, medical technicians, hospitals, or health care providers in the course of obtaining emergency medical attention. The information may also be disclosed to Federal, state, and local officials involved with child care or health services for the purpose of reporting suspected or actual child abuse1. Information may also be disclosed to state public health authorities and/or the Centers for Disease Control for the purpose of reporting communicable diseases. Information released does not contain any personally identifiable information.
All of the DLA forms included in this collection are available electronically as fillable PDF files. Most respondents (95%) choose to complete and submit their forms electronically. The remaining few choose to complete and submit forms in hard copy.
The information obtained through this collection is unique and is not already available for use or adaption from another cleared source.
This information collection does not impose a significant economic impact on a substantial number of small businesses or other small entities.
Less frequent collection of any of the forms listed in this collection may result in CYPs’ inability to provide proper, and sometimes life-saving, care to children enrolled at their facilities.
This collection of information will be conducted in a manner consistent with the guidelines delineated in 5 CFR 1320.5(d)(2).
A 60-Day Federal Register Notice (FRN) for the collection published on Thursday, September 13, 2018. The 60-Day FRN citation is 83 FRN 46485.
During the 60-Day FRN comment period, 1 comment was received. They are included below in the order they were received, as well as our agency’s response to the comment.
Move the Authority, Routine Uses, Disclosure, Privacy Statement, etc. to the end of all of the Action Plan documents (Seizure, Allergy, Diabetes) so that the 9-1-1 protocol sections are on the first page when possible.
Agency Response: We have opted to keep all of the 9-1-1 protocols at the top of the second page of the applicable forms. This allows us to ensure that they are stylistically consistent.
A 30-Day Federal Register Notice for the collection published on Friday, November 23, 2018. The 30-Day FRN citation is 83 FRN 59369.
In addition to public comments solicited via the Federal Register, the forms are derived from official Army forms which were vetted through Army and MEDCOM channels. Additionally, the DLA MWR Health Consultant weighed in on the revision of the forms to meet DLA needs.
No payments or gifts are being offered to respondents as an incentive to participate in the collection.
A Privacy Act Statement (PAS) is included at the beginning of each form used for this collection.
A copy of the System of Records Notice (SORN) for this collection (SORN S400.20), “Day Care Facility Registrant, Applicant and Enrollee Records (May 11, 2012, 77 FR 27740)” has been provided with this package for OMB’s approval.
A Privacy Impact Assessment (PIA) is not required for this collection because PII is not being collected electronically.
Enrollee records (involving no serious accident or injury requiring emergency medical records) are sent to the Child Development and Youth Program Coordinator upon termination from the program and are destroyed one (1) year later.
Enrollee records (involving a serious accident or injury requiring emergency medical records) are sent to the Child Development Services Coordinator upon termination from the program and are destroyed three (3) years after the incident or one (1) year after the enrollee withdraws from the program, whichever is later. Employee and Volunteer Records are maintained at the Child Development Center and are destroyed three (3) years after termination of employment or volunteer services.
This collection of information includes no questions considered sensitive.
DLA Form 1849 Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1849 is collected quarterly, as required.
DLA Form 1849-1 Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1849-1 is collected as required.
DLA Form 1849-2 Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1849-2 is collected once per child.
DLA Form 1849-3 Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1849-3 is collected quarterly, as required.
DLA Form 1849-4 Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1849-4 is collected as required.
DLA Form 1855 Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1855 is collected annually.
DLA Form 1855-1 Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1855-1 is collected annually and as required.
DLA Form 1855-1A Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1855-1A is collected annually.
DLA Form 1855-1B Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1855-1B is collected annually.
DLA Form 1855-1C Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1855-1C is collected annually.
DLA Form 1855-1D, Part I Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 18551-D, Part I is collected annually.
DLA Form 1855-1D, Part II Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1855-1D, Part II is collected annually.
DLA Form 1855-1E Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1855-1E is collected annually.
DLA Form 1855-1F Response Volume (Annual)
Burden per Response
Annual Burden
DLA Form 1855-1F is collected annually.
Burden Summary
Respondent wage was based on a national median hourly wage of $21.90 (rounded up to $22.00) using wage information available from the Bureau of Labor Statistics at https://www.bls.gov. |
DLA assumes the respondent will incur an average insurance co-pay of $30.00 annually, as information provided by the child’s physician is required for a number of the forms associated with this collection. This amounts to $24,840.00 of burden to the public, in addition to the labor burden reported in Section 12.
DLA Form 1849 Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1849-1 Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1849-2 Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1849-3 Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1849-4 Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1855 Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1855-1 Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1855-1A Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1855-1B Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1855-1C Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1855-1D, Part I Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1855-1D, Part II Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1855-1E Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
DLA Form 1855-1F Response Volume (Annual)
Processing Burden per Response
Annual Processing Burden
Burden Summary
Wage information for government employee(s) processing response was based on the following positions/wages:
|
Operational and Maintenance Cost Categories |
|
Equipment |
$ - |
Printing |
$ - |
Postage |
$ - |
Software Purchases |
$ - |
Licensing Costs |
$ - |
Other (Explain) |
$ - |
Total |
$ - |
Cost Summary |
|
Labor Cost |
$10,322.09 |
Operational & Maintenance Cost |
$0.00 |
Total Cost |
$10,322.09 |
This is an existing collection currently in use without an OMB Control Number.
The results of this information collection will not be published.
We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.
We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9.
1 DoD definitions of child abuse and/or neglect shall apply to all programs while also maintaining compliance with any applicable state and Federal laws.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kaitlin Chiarelli |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |