INSTRUCTIONS: Use this form when a single information collection document involves multiple reporting and recordkeeping requirements. The totals of the figures in cols. should be entered in item 13 of OMB-83-I: cols. (D) &/or (I) = 13a (respondent is only counted once); cols. F & I = 13b; cols. H & K = 13c. (F)Total/(D)Total = (E)Average (H)Total/(F)Total = (G)Average (K)Total/(I)Total = (J)Average
NOTE: The columns will calculate automatically. If Col. E's response is something other than annually, i.e., 1/6 years, list as "1/6" & decimal will display.
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TITLE OF INFORMATION COLLECTION DOCUMENT |
OMB NO. |
0560-0190 |
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| Certified State Mediation Program |
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| DATE PREPARED |
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| August 24, 2020 |
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| IDENTIFICATION OF REPORTING OR RECORDKEEPING REQUIREMENT |
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ANNUAL BURDEN |
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REPORTS |
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RECORDS |
RESPONDENT COST |
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TOTAL BURDEN HOURS |
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TOTAL |
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FORMS NO (S) |
NO. OF |
NO OF |
TOTAL ANNUAL |
HOURS |
(Col. F x G) |
NO. OF |
ANNUAL |
RECORD- |
COST |
TOTAL |
| SECTION OF |
DESCRIPTION |
(If "none" |
RESPONDENTS |
RESPONSES |
RESPONSES |
PER |
(H) |
RECORD- |
HOURS PER |
KEEPING HOURS |
PER |
COST |
| REGS. |
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so state) |
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PER |
(Col. D x E) |
RESPONSE |
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KEEPERS |
RECORD- |
(Col. I x J) |
HOUR |
(Col. H x L) |
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RESPONDENT |
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EXEMPT |
NON-EXEMPT |
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KEEPER |
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| (A) |
(B) |
(C) |
(D) |
(E) |
(F) |
(G) |
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(I) |
(J) |
(K) |
(L) |
(M) |
| 785.3(b) |
Recertification |
None |
42 |
3 |
126 |
7.00 |
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882 |
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$55.96 |
49,357 |
| 785.8(a) |
Annual Report |
None |
42 |
3 |
126 |
10.00 |
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1,260 |
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$55.96 |
70,510 |
| 785.8(b) |
Mid-Year Report |
None |
42 |
3 |
126 |
5.00 |
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630 |
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$55.96 |
35,255 |
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0 |
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0 |
| 785.4 |
Request for Advance or Reimbursement (OMB # 4040-0012) |
SF-270 |
42 |
0 |
126 |
1.00 |
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126 |
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0 |
| 785.4(b) |
Application for Federal Assistance** (OMB #4040-0020) |
SF-424 |
42 |
0 |
126 |
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126 |
0 |
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0 |
| 785.4 |
Budget Information for Non-Construction*** (4040-0006) |
SF-424A |
42 |
0 |
126 |
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126 |
0 |
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0 |
| 785.4 |
Assurances Non-Construction** (OMB # 4040-0007) |
SF-424B |
42 |
0 |
126 |
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63 |
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| 785.4 |
Federal Financial Report*** (OMB # 4040-0014) |
SF-425 |
42 |
0 |
126 |
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126 |
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**Collection is included in Recertification Request |
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***Collection is included in the Annual Report |
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SUBTOTAL |
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378 |
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441 |
2,898 |
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0.00 |
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155,121 |
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TOTAL OF ALL PAGES |
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378 |
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441 |
2,898 |
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0.00 |
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155,121 |
| TOTAL - COLUMNS "F" AND "I" = OMB 83-I, 13b; COLUMNS "H" AND "K" = OMB 83-I, 13c |
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378 |
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2,898 |
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