83i

19. Certification for Paperwork Reduction Act Submissions
On behalf of this Federal agency, Icertify that the collection of information encompassed by this request complies with
5 CFR 1320.9.

NOTE: The text of5 CFR 1320.9, and the related provisions of5 CFR 1320.8(b)(3), appear atthe end ofthe
instructions. The certification isto bemade with reference to those regulatory provisions as setforth in
the instructions.

The following isa summary ofthetopics, regarding the proposed collection ofinformation, that the certification covers:
(a) It is necessary for the proper performance ofagency functions;
(b) If avoids unnecessary duplication;
(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that isunderstandable torespondents;

(e) Its implementation will beconsistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents ofthe 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 ofresponse (voluntary, required for a benefit, or mandatory);
(v) Nature and extentofconfidentiality; and
(vi) Need to display currently valid OMB control number;

(h) It was developed by anoffice that has planned and allocated resources for the efficient and effective manage
ment and useoftheinformation to becollected (seenote in Item 19oftheinstructions);

(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate useofinformation technology.

If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason in
Item 18 of the Supporting Statement.

OMB 83-I

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Instructions For Completing OMB Form 83-1
5. Small entities

Please answer all questions and have the Senior Official or
designee sign the form. These instructions should be used

13. Annual reporting and recordkeeping hour burden

Indicate whether this information collection will have a

inconjunction with 5 CFR1320,which provides information
on coverage, definitions, and other matters of procedureand
interpretation under the Paperwork Reduction Act of 1995.

significantimpact on a substantial number of small entities.
A small entitymay be (1) a small business which is deemed
to be one that is independently ownedand operated and

a. Enterthe number of respondentsand/orrecordkeepers.
Ifa respondent is also a recordkeeper, reportthe

1. Agency/Subagency originating request
Provide the name of the agencyor subagency
originatingthe request. For most cabinet-level

agencies, a subagencydesignation is also necessary.
Fornon-cabinet agencies, the subagencydesignation is

that is notdominant in its field of operation; (2)a small
organization that is any not-for-profit enterprise that is
independently ownedand operated and is not dominant in
its field; or (3)a smallgovernment jurisdiction which is a
government of a city, county, town, township, school
district, or specialdistrict with a population of less than
50,000.

generally unnecessary.
2. OMB control number

a. Check "Three years" ifthe agency requestsa threeyear
a. Ifthe information collection in this request has

approval for the collection.

previously received or now has an OMBcontrol or
comment number, enter the number.

b. Check"Other" ifthe agencyrequests approval forless
than three years. Specify the month and year ofthe

b. Check "None" if the information collection in this

requested expiration date.

request has not previouslyreceived an OMB control
7. Title

agency.

official title does notexist, provide a description which will
distinguishthis collectionfromothers.

c. Check"Extension" whenthe collection is currently
approved by OMB, and the agency wishes onlyto
extend the approval past the current expiration date
without making any material change inthe collection
instrument, instructions, frequency of collection, or the
use to which the information is to be put.

d. Check "Reinstatement without change" when the
collectionpreviouslyhad OMB approval, but the
approval has expired or was withdrawn before this

submission was made, and there is no changeto the
collection.

f. Explainthe difference. The difference in line e must be
accounted for in lines f.1. and f.2.

changes.

f.2. "Adjustment" is a change that is not the resultof a
deliberate Federal government action. Changes resulting
from newestimates or action not controllable bythe
Federal government are recorded as adjustments.

9. Keywords

Selectand listat least two keywords (descriptors) from the
"Federal Register Thesaurus of Indexing Terms" that
describe the subject area(s) of the information collection.
Otherterms may be used but should be listedafter those

selected from the thesaurus. Separate keywords with
commas. Keywords should not exceed two lines of text.
10. Abstract

14.Annual reporting and recordkeepingcost burden
(in thousands of dollars)
The costs identified in this item must exclude the cost of
hour burden identified in Item 13.

a. Enter the total dollar amount of annualized cost for all

respondents of any associated capital or start-up costs.

Provide a statement, limited to five lines oftext,covering

submission was made, and there is change to the

11. Affected public

collection.

Mark allcategoriesthat apply, denoting the primary public
with a "P"and all others that applywith"X."

b. Enter recurring annual dollaramount of cost forall
respondents associated with operating or maintaining
systems or purchasingservices.

c. Entertotal (14.a. + 14.b.)annualreporting and
recordkeeping cost burden.

d. Enterany cost burden currently approved byOMB for
this collection of information. Enterzero (0)ifthis is the
first submission after October 1,1995.

not have a currentlyvalid OMB control number.

12. Obligation to respond

4. Type of reviewrequested (check one)
Mark allcategories that apply, denoting the primary
obligation with a "P"and allothers that apply with "X."

standard 60 day reviewschedule.

a. Mark "Voluntary" whenthe response is entirely
discretionary and has no directeffecton any benefit or

b. Check "Emergency" when the agency is submitting
the request under5 CFR1320.13 foremergency

privilege for the respondent.

requests approval.

e. Enterthe difference by subtracting lined from linec.
Record a negative number (d largerthan c) within

comma.

be put, and a brief description of the respondents.

processing and providesthe required supporting
material. Provide the date bywhich the agency

expired.

collectionof information. Separate each form number witha

collection previously had OMB approval, but the
approval has expired or was withdrawn before this

under 5 CFR 1320.10, 1320.11, or 1320.12 with a

d. Enterthe burden hourscurrently approved by OMB for
this collection of information. Enter zero (0)for any new
submission or forany collection whose OMB approval has

subsequent revision of existing collections (e.g.,the
addition or deletion of questions)are recorded as program

the agency's need for the information, uses to which it will

a. Check"Regular" whenthe collection is submitted

burden.

Provide any form number the agency has assigned to this

e. Check "Reinstatement with change" when the

f. Check"Existing collection in use without OMB control
number" whenthe collection is currently in use but does

c. Enter the total annual recordkeeping and reporting hour

8. Agency form number(s) (if applicable)

b. Check "Revision" when the collection is currently
approvedby OMB, and the agency request includesa
material change to the collectioninstrument,
instructions, its frequency of collection, or the use to
which the information is to be put.

(i.e., diskette), electronic mail,or electronic data
interchange. Facsimile is not considered an electronic

f.1. "Program change" is the result of deliberate Federal
government action. All new collectionsand any

a. Check "New collection" when the collection has not

previously been used or sponsored by the agency.

bl Enterthe estimatedpercentageof responses that will
be submitted/collected electronically usingmagnetic media

parentheses.
Provide the official title of the information collection. If an

3. Type of informationcollection (check one)

b. Enterthe number of responses provided annually. For
recordkeeping as compared to reporting activity, the
number of responses equals the number of recordkeepers.

submission.

6. Requested expiration date

number. Enterthe fourdigit agency code foryour

respondent only once.

b. Mark"Requiredto obtain or retain benefits" when the

response is elective, but is required to obtain or retaina
benefit.

c. Check "Delegated" when the agency is submitting

c. Mark "Mandatory" whenthe respondent must reply or

the collection underthe conditions OMB has granted
the agency delegated authority.

face civil or criminal sanctions.

e. Enterthe difference by subtracting lined from linec.
Record a negative number (d largerthan c) within
parenthesis.
f. Explainthe difference. The difference in line e must be
accounted for in lines f.1. and f.2.

f.1. "Program change" is the result of deliberate Federal
government action. All newcollections and any
subsequent revisions or changes resulting incost changes
are recorded as program changes.

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f.2."Adjustment" is a change that is not the resultof a
deliberate Federal government action. Changes
resulting from new estimations or actions not
controllable by the Federal government are recorded
as adjustments.
15. Purpose of information collection

Mark allcategories that apply, denoting the primary
purposewitha "P" and all others that applywith"X."
a. Mark "Application for benefits" whenthe purposeis
to participatein, receive, or qualify for a grant, financial
assistance, etc., from a Federal agency or program.
b. Mark "Program evaluation" when the purpose is a
formal assessment, through objective measures and
systematic analysis, of the manner and extent to which

Federal programs achieve theirobjectivesor produce
other significanteffects.

f. Mark "Research" whenthe purposeis to further the
courseof research, rather thanfora specific program
purpose.

18. Agency contact

Provide the name and telephone numberof the agency
person best able to answer questions regarding the
content of this submission.

g. Mark"Regulatoryor compliance" when the
purpose is to measure compliance withlaws or
regulations.

Submissions

16. Frequencyof recordkeepingor reporting

The SeniorOfficial or designeesigning this statement
certifies that the collection of information encompassed

19. Certification for Paperwork Reduction Act

by the request complies with5 CFR 1320.9. Provisions

Check"Recordkeeping" ifthe collection of information
explicitly includesa recordkeeping requirement.

of this certification that the agency cannotcomply with
should be identified here and fully explainedin item 18 of
the attached Supporting Statement. NOTE: The Office

Check "Third party disclosure" ifa collection of
information includes third-party disclosure
requirements as definedby 1320.3(c).

that "develops" and "uses" the information to be collected

is the officethat "conductsor sponsors" the collection of
information. (See 5 CFR 1320.3(d)).

Check "Reporting" for information collections that
involve reporting and checkthe frequency of reporting
that is requested or required of a respondent. Ifthe
reporting is on "an event" basis, check "On occasion."

c. Mark"General purpose statistics" when the data is

collected chiefly foruse bythe public or forgeneral
government use without primary reference to the policy
or program operations of the agency collecting the
data.

d. Mark "Audit" whenthe purposeis to verify the
accuracy of accounts and records.

e. Mark "Program planning or management"when the
purpose relates to progress reporting,financial
reportingand grants management, procurement and
qualitycontrol,or other administrativeinformation that
does not fit into any other category.

17. Statistical methods

Check "Yes" if the information collection uses

statistical methods such as samplingor imputation.
Generally, check "No" for applications and audits
(unless a random auditing scheme is used). Check
"Yes" for statistical collections, most research

collections, and program evaluationsusingscientific
methods. For other types of data collection,the use
of sampling, imputation, or other statistical estimation
techniques should dictate the response for this item.
Ensure that supporting documentation is provided in
accordance with Section B of the Supporting
Statement.

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Certification Requirement for Paperwork Reduction Act Submissions
5CFR 1320.9 reads "As part of the agency submission to OMB of a proposed collection of information, the agency (through
the head of the agency, the Senior Official, ortheir designee) shall certify (and provide a record supporting such certification)
that the proposed collection of information-

"(a) is necessary for the proper performance of the functions ofthe agency, including that the information to be collected
will have practical utility;

"(b) isnot unnecessarily duplicative of information otherwise reasonably accessible tothe agency;
"(c) reduces totheextent practicable and appropriate the burden on persons who shall provide information toorfor the
agency, including with respect tosmall entities, as defined in the Regulatory Flexibility Act (5 U.S.C. § 601(6)), theuseofsuch
techniques as:

"(1) establishing differing compliance or reporting requirements ortimetables that take into account the resources
available to those who are to respond;

"(2) theclarification, consolidation, orsimplification ofcompliance and reporting requirements; orcollections ofinfor
mation, or any part thereof;

"(3) an exemption from coverage ofthecollection ofinformation, orany part thereof;

"(d) iswritten using plain, coherent, and unambiguous terminology and isunderstandable tothose who aretorespond;

"(e) isto be implemented in ways consistent and compatible, tothe maximum extent practicable, with the existing reporting
and recordkeeping practices ofthose who are to respond;

"(f) indicates for each recordkeeping requirement the length oftime persons are required to maintain the records specified;
"(g) informs potential respondents ofthe information called for under §1320.8(b)(3); [see below]

"(h) has been developed by an office that has planned and allocated resources for the efficient and effective management and
use ofthe information to be collected, including the processing ofthe information in a manner which shall enhance, where
appropriate, the utility ofthe information to agencies and the public;

"(i) uses effective and efficient statistical survey methodology appropriate to the purpose for which the information isto be
collected; and

"(j) to the maximum extent practicable, uses appropriate information technology to reduce burden and improve data quality,
agencyefficiency and responsiveness to the public."
NOTE: 5 CFR1320.8(b)(3) requires that each collection of information:

"(3) informs and provides reasonable notice to the potential persons to whom the collection of information is addressed of:
"(i) the reasonsthe information is planned to be and/or has been collected;

"(ii) the way such information is planned tobeand/or has been used tofurther the proper performance of the functions
of the agency;

"(iii) an estimate, to the extent practicable, of the average burden of the collection (together with a request that the
public direct to the agency any comments concerning the accuracy of this burden estimate and any suggestions for reducing
this burden);

"(iv) whether responses to the collection of information are voluntary, require to obtain or retain a benefit (citing
authority) or mandatory (citing authority);

"(v) thenature and extent ofconfidentiality to be provided, if any (citing authority); and

"(vi) the fact that anagency may not conduct orsponsor, and a person is not required torespond to, a collection of
information unless itdisplays a currently valid OMB control number."

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Supporting Statement for Paperwork Reduction Act Submissions
General Instructions

ASupporting Statement, including the textofthe notice to
the public required by 5 CFR1320.5(a)(i)(iv) and its actual
or estimated date of publication inthe Federal Register,

* requiring respondents to retain records, other than
health, medical, government contract, grant-in-aid, or
tax records, formorethan three years;

must accompany each request for approval of a collectionof

*inconnection with a statistical survey, that is not

12. Provide estimates of the hour burden of the

information. TheSupporting Statement mustbe prepared in

designed to produce validand reliable results that can

collection of information. The statement should:

the format described below,and must contain the
information specifiedin Section A below. Ifan item is not
applicable, provide a briefexplanation. When Item 17 of the
OMB Form83-I is checked "Yes",Section B of the
Supporting Statement mustbe completed. OMB reserves
the rightto require the submission of additional information
with respect to any request for approval.

Specific Instructions
A. Justification

be generalized to the universe ofstudy;

* Indicate the number of respondents, frequency of

* requiring the use of a statistical data classification that

response, annual hour burden, and an explanation of

has notbeen reviewed and approved byOMB;
*thatincludes a pledge ofconfidentiality that is not

do so, agenciesshouldnotconductspecialsurveys

supported by authorityestablished in statute or
regulation, that is not supported by disclosureand data

security policies that are consistentwith the pledge, or
which unnecessarily impedes sharingof data with other
agencies for compatible confidential use; or
*requiring respondentsto submitproprietary trade
secrets, or other confidential information unless the

agency can demonstrate that it has instituted

1. Explainthe circumstances that make the collectionof

procedures to protect the information's confidentiality to

information necessary. Identify any legal or administrative
requirements that necessitatethe collection. Attach a copy
ofthe appropriate section ofeach statute and regulation

the extent permitted by law.

mandating or authorizingthe collectionof information.

2. Indicate how, bywhom, and forwhatpurposethe
information is to be used. Except fora newcollection,
indicate the actual use the agency has made of the
information received from the current collection.

3. Describe whether, and to what extent, the collectionof
information involves the use of automated, electronic,

mechanical, or othertechnological collection techniques or
otherforms of information technology, e.g., permitting
electronic submissionof responses, and the basis forthe
decisionfor adopting this means of collection. Alsodescribe
any consideration of using information technology to reduce

8. Ifapplicable, provide a copyand identify the date
and page number of publication inthe Federal Register
ofthe agency's notice, required by5 CFR 1320.8(d),
soliciting comments on the information collection prior
to submission to OMB. Summarizepublic comments

to obtain information on which to base hour burden

estimates. Consultation with a sample (fewer than
10) of potential respondents is desirable. Ifthe hour
burdenon respondents is expected to varywidely
because of differencesin activity, size, or
complexity, show the range of estimated hour
burden, and explain the reasons for the variance.
Generally, estimates should not include burden
hours for customary and usual business practices.
* Ifthis request for approval covers more than one
form, provide separate hour burden estimates for
each form and aggregate the hour burdens in Item
13 of OMB Form 83-1.
* Provide estimates of annualized cost to

respondents for the hour burdens for collections of

information, identifying and using appropriate wage
rate categories. The cost of contracting out or paying
outside parties for information collection activities
should not be included here. Instead, this cost

hour burden.

should be included in Item 13.

Describeeffortsto consult with persons outside the
agency to obtaintheir viewson the availability of data,
frequency of collection, the clarity of instructions and
recordkeeping, disclosure, or reporting format (ifany),
and on the data elements to be recorded, disclosed, or
reported.

Consultation with representatives of those from whom

4. Describe efforts to identify duplication. Show specifically
whyany similar information already available cannot be

compile recordsshouldoccurat least once every3
years- even ifthe collection of information activity is
the same as in prior periods. Theremay be

information is to be obtained or those who must

used or modified for use forthe purposes described in Item

how the burden was estimated. Unless directed to

received in response to that notice and describe actions
taken by the agency in response to these comments.
Specifically address comments received on cost and

burden.

2 above.

is requested, and any steps to be taken to obtain
their consent.

circumstances that may preclude consultation in a
specific situation. These circumstances should be
explained.

13. Provide an estimate for the total annual cost

burden to respondentsor recordkeepers resulting
from the collection of information. (Do not include
the cost of any hour burden shown in Items 12 and
14).
*The cost estimate should be split intotwo
components: (a) a total capital and start-up cost
component(annualized over its expected usefullife)
and (b) a total operationand maintenance and
purchase of services component.The estimates
should take into account costs associated with

statute, regulation, or agency policy.

generating, maintaining, and disclosing or providing
the information. Include descriptions of methods
used to estimate major cost factors including system
and technology acquisition, expected useful life of
capital equipment, the discount rate(s),and the time
period overwhich costs will be incurred. Capital and
start-upcosts include, amongotheritems,
preparationsfor collecting information such as
purchasing computers and software; monitoring,
sampling, drilling and testingequipment; and record

information collection to be conducted in a manner:

11. Provide additional justification forany questions of a

* Ifcost estimates are expected to vary widely,

*requiring respondents to report information to the agency

sensitive nature, such as sexual behavior and attitudes,

more often than quarterly;
*requiring respondentsto preparea written response to a
collection of information infewer than 30 days after receipt

religious beliefs, and othermattersthat are commonly
considered private. Thisjustification shouldinclude the
reasons whythe agency considers the questions

agencies should present ranges of cost burdens and
explain the reasons for the variance. The cost of

5. Ifthe collection of information impacts small businesses
or other small entities (Item5 of OMB Form 83-I), describe
any methods used to minimize burden.

9. Explain anydecision to provide any payment or gift

6. Describe the consequence to Federal program or policy

to respondents, other than reenumeration of
contractors or grantees.

activities if the collection is not conducted or is conducted

less frequently, as well as any technical or legal obstacles

10.Describe anyassurance ofconfidentiality provided

to reducing burden.

to respondents and the basis for the assurance in

storage facilities.

7. Explain any special circumstances that would cause an

of it;

necessary, the specific uses to be made of the

*requiring respondents to submit more thanan original and

information, the explanation to be given to personsfrom

twocopies of any document;

whom the information

purchasingor contracting out information collections
services should be a part of this cost burden
estimate. Indeveloping cost burden estimates,
agencies may consult with a sample of respondents
(fewer than 10),utilize the 60-day pre-OMB
submission public commentprocess and use

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existing economic or regulatory impact analysis
associated with the rulemaking containing the
information collection, as appropriate.
*Generally, estimates should not include
purchases of equipmentor services, or portions
thereof, made:(1) prior to October1,1995, (2)to
achieve regulatory compliance with requirements
not associated withthe information collection, (3)
for reasons other than to provide infomiation or
keep recordsforthe government, or (4)as part of
customary and usual business or private
practices
14. Provide estimates of annualized costs to the

Federalgovernment. Also, providea description of
the method used to estimate cost, which should

include quantification of hours, operational
expenses (such as equipment, overhead, printing,
and supportstaff), and any other expense that
would not have been incurred without this

collection of information. Agenciesmay also
aggregate cost estimates from Items 12,13, and
14 in a singletable.
15. Explain the reasons for any program changes
or adjustments reported in Items 13 or 14 of the
OMB Form 83-I.

17. Ifseekingapproval to notdisplay the expiration
date for OMB approval of the infomiation collection,
explainthe reasons that displaywould be
inappropriate.

18. Explain each exceptionto the certification
statement identified in Item 19, "Certificationfor
Paperwork Reduction Act Submissions," of OMB Form
83-I.

will be published, outline plans for tabulation and

publication. Address any complex analytical
techniques that will be used. Provide the time
schedule forthe entire project, including beginning
and ending dates of the collectionof information,

selection,

* Estimation procedure,
* Degreeof accuracy needed forthe purpose described in
the justification,

*Unusual problems requiring specialized sampling
procedures, and

*Any use of periodic (less frequent than annual) data
B. Collections of Information Employing

collectioncycles to reduce burden.

Statistical Methods

The agencyshouldbe prepared to justify its decision not to
use statistical methods in any case where such methods
might reduce burdenor improve accuracy of results. When
Item 17 on the Form OMB83-I is checked, "Yes," the

following documentation should be included in the
Supporting Statementto the extendthat it applies to the

3. Describemethods to maximize response rates and to
deal with issues of non-response. The accuracyand
reliability of information collected must be shown to be
adequate for intended uses. For collections based on

sampling, a special justification must be provided forany
collection that will not yield "reliable" data that can be
generalizedto the universe studied.

methods proposed:
4. Describe any tests of procedures or methods to be
undertaken. Testing is encouraged as an effective means

1. Describe (including a numerical estimate)the
potential respondent universe and any sampling or
other respondent selection methods to be used. Data
on the number of entities (e.g., establishments, State

and local government units, households, or persons)
16. For collections of information whose results

2. Describe the procedures for the collectionof information
including:
* Statistical methodology forstratification and sample

in the universe covered by the collection and inthe
corresponding sample are to be providedin tabular
form for the universe as a whole and for each of the

strata in the proposedsample. Indicateexpected
response rates for the collection as a whole. Ifthe

completion of report, publication dates, and other

collection had been conducted previously, include the
actual response rate achieved duringthe last

actions.

collection.

of refining collections of information to minimize burdenand
improve utility. Tests must be approved ifthey call for
answers to identical questions from 10 or more
respondents. A proposed test or set of test may be

submitted forapproval separatelyor incombination with the
main collection of information.

5. Provide the name and telephone number of individuals

consulted on statistical aspects of the design and the name
of the agency unit,contractor(s),grantee(s), or other
person(s) whowill actually collect and/oranalyzethe
information for the agency.

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