83-c

Paperwork Reduction Act

Change Worksheet

Agency/Subagency: U.S. Department of Housing and Urban Development			OMB Control Number: 2528-0337
Enter only items that change		Current Record		New Record**
Agency form number(s):      		     		     
Annual reporting and keeping hour burden
	Number of respondents	     		     
	Total annual responses	     		     
	Percent of these responses collected electronically	    %		    %
	Total annual hours	     		     
	Difference			     
	Explanation of difference Program change Adjustment			           
Annual reporting and recordkeeping cost burden (in thousands of dollars)
	Total annualized Capital/Startup costs	     		     
	Total annual costs (O&M)	     		     
	Total annualized cost requested	     		     
	Difference			     
	Explanation of difference Program change Adjustment			           

Other change: **

Revision to Instrument 1 Household Roster and Baseline Information From to add response options to Question 5. The new response options will: 1. Document that the parent/guardian providing permission for the child to participate lives in the household, even if they are not the head of household; 2. Track the name of the parent/guardian providing permission; and 3) Document the relationship between the parent/guardian and child to ensure the person is able to provide consent. The revisions do not affect the burden estimate for the data collection.

Signature of Senior Official or Designee: X

Date:

For OIRA Use

** This form cannot be used to extend an expiration date.

OMB 83-C 10/95