Suspension and Debarment and Drug-Free Workplace Certifications

Forms and Documents

Document Name	Status
Form AD-1050 Suspension and Debarment and Drug-Free Workplace Certifications Form and Instruction	Modified
Change Justification (OMB Control No 0505-0027) Forms AD-1049 AD-1052.docx Justification for No Material/Nonsubstantive Change	2019-10-17
Change Justification.docx Justification for No Material/Nonsubstantive Change	2019-07-11
Copy of 0505-0027 2018 SDDFWP Certs - APPENDIX I.xlsx Supplementary Document	2019-02-12
0505-0027 2018 SStmt Final (USDA SD DFWP Certs) 2-11-19.docx Supporting Statement A	2019-02-12

IC Document Collections

IC ID	Document Title	Status
217590	Suspension and Debarment and Drug-Free Workplace Certifications Form and Instruction	Modified

ICR Details

OMB Control No: 0505-0027	ICR Reference No: 201910-0505-002
Status: Active	Previous ICR Reference No: 201907-0505-002
Agency/Subagency: USDA/OCFO	Agency Tracking No:
Title: Suspension and Debarment and Drug-Free Workplace Certifications
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/23/2019
	Date Received in OIRA: 10/17/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022	04/30/2022	04/30/2022
Responses	1	0	1
Time Burden (Hours)	1	0	1
Cost Burden (Dollars)	0	0	0

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Abstract: To certify information on applicant suitability concerning distribution of financial assistance in compliance with Federal Suspension and Debarment and Drug-Free Workplace regulations.

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Authorizing Statute(s): US Code: 41 USC 8101 Name of Law: Drug-Free Workplace
  

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 49353	10/01/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 66238	12/26/2018
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Suspension and Debarment and Drug-Free Workplace Certifications	AD-1047, AD-1048, AD-1049, AD-1050, AD-1052	Certofocatopm Regarding Drug-Free Workplace Requirements (Grants) Alternative II - For Grantees Who are Individuals ,   Certification Regarding Drug-Free Workplace State and State Agencies, Federal Fiscal Year ,   Certification Regarding Debarment, Suspension, and Other Responsibility Matters Primary COvered Transactions ,   Cdrtification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions ,   Certification Regarding Drug-Free Workplace Requirements (Grants) Alternative I - For Grantee Other Than Individuals

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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	1	1	0	0	0	0
Annual Time Burden (Hours)	1	1	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:

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Annual Cost to Federal Government: $0

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.     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: 10/17/2019

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