Information Collection

OSHS Cooperative Agreement

IC 230476 under ICR 202004-1220-004 · OMB 1220-0149.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1220-0149 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OSHS FRW - A OSHS Cooperative Agreement	Form and Instruction
OSHS FRW - A Financial Reconciliation Worksheet OSHS FRW - A Fillable-2019.pdf	Form and Instruction
OSHS FRW - B Financial Reconciliation Worksheet OSHS FRW - B Fillable-2019.pdf	Form and Instruction
BLS-OSHS2 Quarterly Financial Report BLS-OSHS2 - Fillable - 2019.pdf	Form and Instruction
OSHS CA BV Budget Variance Request Form OSHS COOPERATIVE AGREEMENT BUDGET VARIANCE REQUEST FORM.PDF	Form and Instruction
Property Listing Property Listing OSHS Property Listing - Fillable - 2019.pdf	Form and Instruction
OSHS TCF Transmittal and Certification Form BLS - OSHS TCF - Fillable - 2019.pdf	Form and Instruction
OSHS CA OSHS Cooperative Agreement Work Statement FY 2021 OSHS CA.docx	Form and Instruction
OSHS Agent Agreeme OSHS Agent Agreement OSHS BLS Agent Agreement.pdf	Form
Pre-Release Access Pre-ReleaseAccess Certification Form BLS Pre-Release Access Certification.pdf	Form

IC Title:

OSHS Cooperative Agreement

Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OSHS FRW - A	Financial Reconciliation Worksheet	OSHS FRW - A Fillable-2019.pdf	Yes	No	Fillable Printable
Form and Instruction	OSHS FRW - B	Financial Reconciliation Worksheet	OSHS FRW - B Fillable-2019.pdf	Yes	No	Fillable Printable
Form and Instruction	BLS-OSHS2	Quarterly Financial Report	BLS-OSHS2 - Fillable - 2019.pdf	Yes	No	Fillable Printable
Form and Instruction	OSHS CA BV	Budget Variance Request Form	OSHS COOPERATIVE AGREEMENT BUDGET VARIANCE REQUEST FORM.PDF	Yes	No	Fillable Printable
Form and Instruction	Property Listing	Property Listing	OSHS Property Listing - Fillable - 2019.pdf	Yes	No	Fillable Printable
Form and Instruction	OSHS TCF	Transmittal and Certification Form	BLS - OSHS TCF - Fillable - 2019.pdf	Yes	No	Fillable Printable
Form and Instruction	OSHS CA	OSHS Cooperative Agreement Work Statement	FY 2021 OSHS CA.docx	Yes	No	Fillable Printable
Form	OSHS Agent Agreement	OSHS Agent Agreement	OSHS BLS Agent Agreement.pdf	Yes	Yes	Fillable Fileable
Form	Pre-Release Access Certification Form	Pre-ReleaseAccess Certification Form	BLS Pre-Release Access Certification.pdf	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	445	445
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.