Counseling Information Form; Regional Center Intake Form and Quarterly (formerly Monthly) Report of Operations Form.

Forms and Documents

Document Name	Status
Form DOT F 4500 The Regional Center Intake Form Form and Instruction	Unchanged
OSDBU_2105-0554_Supporting Statement_Renewal.doc Supporting Statement A	2019-07-26
30-Day_Notice_20150554_26_July2019__84FR36160.pdf Supplementary Document	2019-07-26
2105-0554_60-day_Notice_84.FR.23827_May.23.2019_Regional_Field_Offices_Intake_Form.pdf Supplementary Document	2019-07-25
MRC _ Statute.pdf Supplementary Document	2008-10-06

IC Document Collections

IC ID	Document Title	Status
203950	The Regional Center Intake Form Form and Instruction	Unchanged

ICR Details

OMB Control No: 2105-0554	ICR Reference No: 201907-2105-002
Status: Active	Previous ICR Reference No: 201602-2105-004
Agency/Subagency: DOT/OST	Agency Tracking No:
Title: Counseling Information Form; Regional Center Intake Form and Quarterly (formerly Monthly) Report of Operations Form.
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/09/2019
	Date Received in OIRA: 07/30/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2022	36 Months From Approved	09/30/2019
Responses	100	0	100
Time Burden (Hours)	600	0	600
Cost Burden (Dollars)	0	0	0

---

Abstract: The Office of Small and Disadvantaged Business Utilization administers the provisions of Title 49, of the United States Code, Section 332, the Minority Resource Center (MRC) which includes the duties of advocacy, outreach, and financial services on behalf of small and disadvantaged businesses and those certified under CFR 49 parts 23 and or 26 as Disadvantaged Business Enterprises (DBE).Show citation box The collection involves the use of the Regional Center Intake Form (DOT F 4500) and use of Regional Resource Center Quarterly (formerly Monthly) Report Form (DOT F 4502). SBTRC's Regional Field Offices will collect information on small businesses and types of services they seek from the Regional Field Offices. People filling out the Regional Field Offices Intake Form (DOT F 4500) are paid with grant money from the Federal Government, so the participant are not spending any money of their on preparing and submitting reports.

---

Authorizing Statute(s): US Code: 49 USC Section 332 Name of Law: Minority Resource Center (MRC)
   PL: Pub.L. 95 - 507 8,15, and 31 Name of Law: Small Business Act (SBA)
  

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:
	84 FR 23827	05/23/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 23827	07/26/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
The Regional Center Intake Form	DOT F 4500	The Regional Center Intake Form

---

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	100	100	0	0	0	0
Annual Time Burden (Hours)	600	600	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	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:

---

Annual Cost to Federal Government: $7,758

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.     No

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.     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

---

Common Form ICR:  No

---

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: 07/30/2019

---