Information Collection

Suspension and Debarment and Drug-Free Workplace Certifications

IC 217590 under ICR 202204-0505-001 · OMB 0505-0027.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0505-0027 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD-1047 Suspension and Debarment and Drug-Free Workplace Certifications	Form and Instruction
AD-1047 Certification Regarding Debarment, Suspension, and Other AD-1047_20220428-Sec508.pdf	Form and Instruction
AD-1047 Certification Regarding Debarment, Suspension, and Other AD-1047_20220428-Sec508.pdf	Form and Instruction
AD-1048 Cdrtification Regarding Debarment, Suspension, Ineligibi AD-1048_20220428-Sec508.pdf	Form and Instruction
AD-1048 Cdrtification Regarding Debarment, Suspension, Ineligibi AD-1048_20220428-Sec508.pdf	Form and Instruction
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD-1049_20220428-Sec508.pdf	Form and Instruction
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD-1049_20220428-Sec508.pdf	Form and Instruction
AD-1050 Certofocatopm Regarding Drug-Free Workplace Requirements AD-1050_20220428-Sec508.pdf	Form and Instruction
AD-1050 Certofocatopm Regarding Drug-Free Workplace Requirements AD-1050_20220428-Sec508.pdf	Form and Instruction
AD-1052 Certification Regarding Drug-Free Workplace State and St AD-1052_20220428-Sec508.pdf	Form and Instruction
AD-1052 Certification Regarding Drug-Free Workplace State and St AD-1052_20220428-Sec508.pdf	Form and Instruction

IC Title:

Suspension and Debarment and Drug-Free Workplace Certifications

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	AD-1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters Primary COvered Transactions	AD-1047_20220428-Sec508.pdf	Yes	No	Fillable Fileable
Form and Instruction	AD-1048	Cdrtification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions	AD-1048_20220428-Sec508.pdf	Yes	No	Fillable Fileable
Form and Instruction	AD-1049	Certification Regarding Drug-Free Workplace Requirements (Grants) Alternative I - For Grantee Other Than Individuals	AD-1049_20220428-Sec508.pdf	Yes	No	Fillable Fileable
Form and Instruction	AD-1050	Certofocatopm Regarding Drug-Free Workplace Requirements (Grants) Alternative II - For Grantees Who are Individuals	AD-1050_20220428-Sec508.pdf	Yes	No	Fillable Fileable
Form and Instruction	AD-1052	Certification Regarding Drug-Free Workplace State and State Agencies, Federal Fiscal Year	AD-1052_20220428-Sec508.pdf	Yes	No	Fillable Fileable

Line of Business: Natural Resources

Subfunction: Agricultural Innovation and Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
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.