Appendix D - Major Changes Quarterly Reporting Template.xlsx

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Overview

Data Reporting
OMB Disclosure

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Sheet 1: Data Reporting

Major Changes Quarterly Reporting Template								OMB Number: 0584-0579 Expiration Date: 04/30/2023
Fiscal Year:
State Name:
State Contact Person:
Contact Person's E-mail Address:
Contact Person's Telephone Number:
Date Major Change Implemented:
DATA ELEMENTS		HOUSEHOLD ("HH") TYPE	MONTH
			Jun-17	Jul-17	Aug-17
Initial Applications Received ("Apps Rec'd")	Before completing this worksheet, please work with FNS HQ to determine what type of sub-state level data is appropriate for your major change Total Number ("No.") of Initial Apps Rec'd	Regular HHs
		Elderly/ Disabled HHs
	No. of Initial Apps Rec'd In Person	Regular HHs
		Elderly/ Disabled HHs
	No. Initial Apps Rec'd Online	Regular HHs
		Elderly/ Disabled HHs
	No. of Initial Apps Rec'd by Phone	Regular HHs
		Elderly/ Disabled HHs
	No. of Initial Apps Rec'd by Mail	Regular HHs
		Elderly/ Disabled HHs
	No. of Initial Apps Rec'd by Fax	Regular HHs
		Elderly/ Disabled HHs
Initial Application ("Initial Apps") Processing Timeliness	No. of Initial Apps Approved Timely	Regular HHs
		Elderly/ Disabled HHs
	No. of Initial Apps Approved Timely that were Subject to Expedited Processing Requirement	Regular HHs
		Elderly/ Disabled HHs
	No. of Initial Apps Approved Untimely	Regular HHs
		Elderly/ Disabled HHs
	No. of Initial Apps Approved Untimely that were Subject to Expedited Processing Requirement	Regular HHs
		Elderly/ Disabled HHs
	No. of Initial Apps Denied	Regular HHs
		Elderly/ Disabled HHs
	No. of Initial Apps Denied Due to Ineligibility	Regular HHs
		Elderly/ Disabled HHs
	No. of Initial Apps Denied Due to State Agency's Inability to Determine Eligiblity	Regular HHs
		Elderly/ Disabled HHs
Recertification Applications Received ("Recerts Rec'd")	No. of HHs Due for Recertification	Regular HHs
		Elderly/ Disabled HHs
	No. of Recerts Rec'd	Regular HHs
		Elderly/ Disabled HHs
	No. of Recerts Rec'd In Person	Regular HHs
		Elderly/ Disabled HHs
	No. of Recerts Rec'd Online	Regular HHs
		Elderly/ Disabled HHs
	No. of Recerts Rec'd by Phone	Regular HHs
		Elderly/ Disabled HHs
	No. of Recerts Rec'd by Mail	Regular HHs
		Elderly/ Disabled HHs
	No. of Recerts Rec'd by Fax	Regular HHs
		Elderly/ Disabled HHs
Recertification Applications ("Recert Apps") Processing	No. of HHs Recertified w/o Delay/Break in Benefits	Regular HHs
		Elderly/ Disabled HHs
	No. of HHs Recertified w Delay/Break < 1 month	Regular HHs
		Elderly/ Disabled HHs
	No. of HHs Due for Recertification that Failed to Reapply by Deadline	Regular HHs
		Elderly/ Disabled HHs
	No. of Recert Apps Denied	Regular HHs
		Elderly/ Disabled HHs
	No. of Recert Apps Denied Due to Ineligibility	Regular HHs
		Elderly/ Disabled HHs
	No. of Recert Apps Denied Due to State Agency's Inability to Determine Eligiblity	Regular HHs
		Elderly/ Disabled HHs

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Sheet 2: OMB Disclosure

This information is being collected to assist the Food and Nutrition Service meet the requirements of 7 CFR 272.15. This is a mandatory collection and FNS uses the information to monitor major change implementations. This collection does not request any personally identifiable information under the Privacy Act of 1974. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0579. The time required to complete this information collection is estimated to average 70 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22306 ATTN: PRA 0584-0579. Do not return the completed form to this address.